UNITED STATES FLEET 
UNITED STATES NAVAL FORCES, GERMANY, 
SENIOR U. S. NAVAL LIAISON OFFICER, 
ATTN: TECHNICAL SECTION (MEDICAL) , 
Room 111, Headquarters 
Fourth Medical Laboratory 
Heidelberg/Germany 
APO 403, U.S. Army 
File; P 3 - 1 (b) 
Serial; 2$1-Med. 
30 September 1948 
From: 
Senior U. S. Naval Liaison Officer, European Command, 
U. S. Army, APO 403. 
TO; 
Chief of the Bureau of Medicine and Surgery, 
Attn: Chief, Publications Division. 
Via; 
(1) Technical Officer, U.S. Naval Forces, Germany. 
(2) Chief of Naval Operations (0p-32-F2). 
Subject; 
Report of the First Conference of the Medical Consultants 
to the German Armed Forces - Forwarding of Translation of. 
Reference: (a) Letter P 3-l(b), Serial 207, dated 2 January 1948 from 
Head, Medical Section, Technical Office, Office of the Naval 
Advisor, OMGUS. 
(b) Letter P 3-l(b), Serial 208, dated 2 January 1948 from 
Head, Medical Section, Technical Office, Office of the Naval 
Advisor, OMGUS. 
(c) Letter P 3-l(b), Serial 224, dated 26 February 1948 
from Assistant Technical Officer (Medical) U.S*Naval Forces, 
Germany. 
(d) Letter P 3-l(b), Serial 232, dated 24 March 1948, from 
Assistant Technical Officer, (Medical) U,s. Naval Forces, 
Germany. 
Enclosure; (a) Subject Translation (project I, Folios IX and X). 
1* Due to its bulk Enclosure (A) will be forwarded under 
separate cover direct to each of the below listed recipients of a copy 
of this letter. 
2. This is the final portion of Project I of this section, 
parts of which have been forwarded previously by references (a), (b), 
(c) and (d). 
3. The editing of these folios was completed by Commander 
Harry J. ALVIS, (MC), USN., as Head of the Medical Section before his 
return to the U.S. The mechanical completion of the folios was con- 
tinued by a portion of the medical section which is presently operat- 
ing under the administrative supervision of the Senior U. S, Naval 
Liaison Officer, EUCOM, HQ., APO 403. 
4. The reserve supply of these folios is limited. It will 
be forwarded to the Bureau of Medicine and Surgery, Publications Division 
on a Government Bill of Lading. Requests for additional copies or fur- 
ther distribution should be addressed to that office. 
N. W.' ABRAHAMS, 
Captain, U.S.N. 
cc: 
ONA, OMGUS 
CNO (0p-32-F2) 
BUMED (publications Div.) 
BUMED (Research Div.) 
BUMED (Professional Div.) 
BUMED (Prev.Med.Div.) 
U.S. Army Medical Library 
N.M.R.I. Bethesda 
Naval Med.School, 
Bethesda 
Dept.of Army Surg.Gen. 
Med.Intell.Sect. 
Dept.of Air Force, 
. J&r Surg.Med.Int.Sect, 
U.S.Publ.Health Serv. 
Off.of Surg.Gen. 
U.S.Dept.Commerce, 
Off.Techn.Info. NAVAL TECHNICAL UNIT, EUROPE 
OFFICE OF NAVAL ADVISOR 
OFFICE OF MILITARY GOVERNMENT FOR GERMANY (U.S.) 
Medical Section 
Room 124, EUCOM HDQTRS. 
FOREWORD TO THE TRANSLATION 
OF THE REPORT OF THE FIRST CONFERENCE OF THE MEDICAL CONSULTANTS TO THE 
GERMAN ARMED FORCES. 
These folios (IX and X) contain the translation of the report of 
the First Conference of the Medical Consultants for the German Armed 
Forces held 18 to 19 May 1942 at the Military Medical Academy, Berlin, 
Germany, They are of interest in that the problems encountered in the 
previous winter on the Russian Front are discussed. This meeting was 
the first general meeting held after the reorganization of the high 
command and the assumption of supreme authority by Hitler. 
The practice of holding such conferences and of having a medical 
consultant group was as old as the history of the medical service of 
the German army and may be said to date back to the days of Frederick 
the Great. Under one plan of organization after another the practice 
had been continued, until it came to this form in the late war* A Med- 
ical Inspectorate was established over the Medical Services of the 
various branches of the Armed Forces, A scientific consultants group 
was formed from the various similar groups of the branches of the Armed 
Forces and it was this confined group that met here for the first time 
and thus this was called the First Conference, 
The distribution of this translation brings to a close the original 
project of this section. Approximately 1000 pages of German text have 
been translated to complete this series of ten folios. Taken together 
they give a fairly complete cross section of the problems confronting 
the Germans after the first winter of the Russian campaign. It was 
possible to complete this work only by the cooperation of many elements. 
The photostatic copy of the original text from which the translations 
were made was loaned to this section by Lt. Col. James BLAISDELL, 
Medical Corps, Royal Canadian army, while he was Head, Scientific Branch, 
F.I.A.T. (British). Encouragement and cooperation was received from 
many offices of the European Command, U.S. Army and U.S. Naval Forces, 
Germany. If special note is given anyone it will have to be the group 
of unnamed German translators who hour after weary hour slogged on 
through the wilderness and vagaries of technical terminology in trying 
to produce an understandable translation of ideas without changing the 
general format. From beginning to end it has been the attempt to set 
down sentence by sentence, in the same order as found in the original 
text, the ideas expressed there. Only one who has contended with this 
problem can appreciate what that means. The editing of the preliminary 
translations is looked back on as a sort of translators Pilgrim*s Pro- 
gress. No misconception is held that these translations are an example 
of English literary style, Reading the various drafts of the trans- 
lations was exhausting but never dull. It is believed that the reader 
will find them interesting and sometimes surprising if he will think 
of them as problems that were matters of concern. Why this should be 
in some cases is an unanswered question. The trend of some of the dis- 
cussions at times makes interesting reading even though one does not 
agree with the opinions stressed. So once again the last has come first and the first has come last 
and the job is aone. We close the cover on the last folio knowing 
that whether these translations are ever used or not they will occupy 
a prominent place. Even though it may be on some forgotten dusty 
shelf far back in the files they occupy so much space that even there 
they will be seen from time to time, though mayhap only from the out- 
side. For the sake of a weary humanity the hope is expressed that 
such a series of reports will never again be compiled. 
HARRY J. ALVIS, 
Commander, Medical Corps, 
U. S, Navy. INDEX im 
REPORT 
OF THE 
FIRST CONFERENCE 0? SPECIAL MEDICAL CONSULTANTS 
18 - 19 MAY 1942 
MILITARY MEDICAL ACADEMY, BERLIN, 
Translation prepared by; 
Office of Military Government for Germany (U. S.) 
Office of Naval Advisor 
Medical Section I 
TITLE 
PAGE 
Preface to the Report 2 
Speech of the Army Medical Inspector 3 
I. Amputation Technique 9 
1. Amputation technique* (Abstract). 
Oberfeldarzt (Lt.Col., MC.) Prof. FREY 10 
II. Gunshot Injuries of the Brain and their Treat- 
ment, "Cooperation between'Neurologists 
and Surgeons. 13 
1. Gunshot injuries of the brain,(Abstract) 
Oberstabsarzt (Major, MC.) Prof, T0EPHI3 14 
2* Concerning the cooperation with the 
neurologists in case of treatment of 
soldiers suffering from gunshot Injuries 
of the brain. 
Oberstabsarzt (Major, MC.) Prof. v.STOCKEP.T 14 
III. The Treatment of Fresh Par bounds by Cautery 24 
1. Short survey concerning the development of 
this method. 
Oberfeldarzt (Lt.Col., MC,) Prof* ’.7ACHSMUTH 2$ 
V 
2, Success and effect of the treatment by cautery. 
Stabsarzt (Captain, MC.) POECP. 2$ 
IV. Chemotherapy of the Pound Infections 27 
Chemotherapy of the wound infections 
Oberstabsarzt (Major, MC.) Prof. ROSTOCK 23 
V. Evacuation of the Wounded 36 
Evacuation of the wounded 
Oberfeldarzt (Lt.Col., MC.) Prof. WACHSMUTH 37 
VI. Typhus, Wolhynia Fever, Relapsing Fever 41 
A. Typhus 
1. Variations in the clinical course, clinical 
prognosis, late damages, subsequent sequelae, 
Typhus-encephalitis, Peil-Felix reaction, 
Otto and Peigl vaccines, dust from fecal 
matter of lice. Reko-serum, time of admin- 
istration. Therapy. 
Stabsarzt (Captain, MC.) Prof. BRINKMAHN 42 
2. Variations in the clinical course, clinical 
prognosis, late damages, subsequent sequelae, 
Typhus-encephalitis, Peil-Felix reaction, 
Otto and Weigl vaccines, dust from fecal 
matter of lice, Reko-serum, time of admin- 
istration. Therapy. 
Oberarzt (1st Lieut., MC.) Dozent SCHULZE 50 TITLE 
PAGE 
3. Disinfestation, lice powder, infection by 
fecal matter of lice. Is disinfection 
necessary in addition to disinfestation? 
Oberstabsarzt (Major, MC•) Dozent EYSH 55 
4, The exanthematlc typhus occurring in this war 
as compared to that observed from 1914 to 
1918. 
Ober stabsarzt (Major, HC.) Prof. GRUBER 57 
B. Trench Fever (Wolhynian Fever) 72 
Differences as opposed to the experience of 
World War I. Measures against it. Therapy. 
Oberstabsarzt (Major, MC.) Prof, BCGENDOEREER 72 
C. Recurrent Fever 78 
1. Lecture by 
Oberfeldarzt (Lt.Col., MC.)Prof.RODENWALDT 78 
2. Lecture by 
Oberfeldarzt (Lt.Col., MC.) Prof. KOCH 79 
VII. Bacillary and Amebic Dysentery. 
(Annex: Cleaning of fruits)' 81 
a) Bacillary Dysentery 
1. Prophylaxis, Therapeutic Aspects. 
Oberstabsarzt (Major, MC.) Prof. ASSMANN 82 
2. Immunization, bacteriophages (Preservation 
and transportation of.) 
Kriegsarzt Dr. VISRTHALER 8? 
3. Confused and disputed problems of patho- 
genesis. 
Oberstabsarzt (Major, MC.) Prof. LETTERER 88 
Annex 
The disinfection of raw vegetables and fruits 
in the tropics. 106 
Memorandum concerning Amebi c Dysentery. 
General Rules. 1°7 
VIII* War Nephritis 115 
1. Clinical variations, etiology, geographical 
distribution. 
Oberstabsarzt (Major, MC.) Prof. VOIGT llo 
2. Doubtful problems, anatomical difference be- 
tween war and ordinary nephritis, 
Stabsarzt (Captain, MC.) Prof. EANDERATH 120 TITLE 
PAGE 
IX. Diphtheria 12? 
1. Early diagnosis, therapy except for serum 
therapy, pharyngeal and wound diphtheria, 
bacillus carriers, active and passive im- 
munization. 
Oberstabsarzt (Major, MC.) Prof. VOIT 128 
2. Treatment of diphtheria with in the units, 
active immunization, reference is made to 
the present epidemiology of the diphtheria. 
Oberstabsarzt (Major, MC. ) Prof. CLAUBTORG 131 
X. Typhoid Fever 136 
The epidemic in Paris and the experience 
gained with regard to immunization. 
Oberfeldarzt (Lt.Col., MC.) KPSY 139 
XI. Tularemia 146 
1. Diagnosis, agglutination, skin reactions, 
epidemiology and serology. 
Oberstabsarzt (Major, MC.) Prof.BOGENDOEREER 147 
2. Distribution, length of sickness, serological 
dia gnosi s * 
Oberfeldarzt (Lt. Col., MC.) Prof. BISLING 149 
3. Pathologyf anatomy, and histology of the 
tularemia. 
Oberfeldarzt (Lt.Col., MC.) Prof. LAUCHE 134 
XII. Injuries due to Cold 163 
1. Prophylaxis (Abstract) 
Stabsarzt (Captain, MC.) Prof. KILIAN 164 
2, Pathological findings with injuries due to 
cold, inanition impairments. 
Oberstabsarzt (Lt.Col., MC.) Prof.SIEGMUND 174 
XIII. Diminished Resistance 189 
1. Opinion on 
a) the development of injuries due to cold 
b) the distribution of infectious diseases. 
Stabsarzt (Captain, MC .) Prof. WOHLESIL '190 
2. Disposition to infection, altered course of 
diseases, occurrence of intestinal dieseases. 
Oberstabsarzt (Major, MC.) Prof. ASSMANN 192 
3. Diminished resistance and inanition. 
Oberstabsarzt (Major, MC.) Prof. KRAU3PE 198 IV 
TITLE 
PAG-1 
XIV. Treatment of Psychogenic Reactions 203 
1. The problem of psychopaths with the Field 
Army. 
Ober stabsar zt (Major, MC .) Prof. Dr. 
P. SCHNEIDER 204 
2. Treatment of war neurotics. 
Oberstabsarzt (Major, MC.) Prof. 
CARL SCHNEIDER 213 
XV. The Sulfonamide Treatment of Neurologic Diseases 223 
1. The sulfonamide treatment of neurological 
di senses. 
Oberstabsarzt (Major, MC.) CHFISTUKAT 224 REPORT 
OF THE 
FIRST CONFERENCE OF SPECIAL MEDICAL CONSULTANTS 
18 - 19 MAY 194-2 
MILITARY MEDICAL ACADEMY, BERLIN. 
Translation prepared by: 
Office of Military Government for Germany (U. S* ) 
Office of Naval Advisor 
Medical Section 2 
PREFACE TO THE REPORT 
On 18th and 19th of May 1942 the First Conference on 
the problems concerning the war in the East was held in 
Berlin. It was the purpose of this conference to check 
on the directions and instructions in the field of medical 
science issued during the past time by consultation of 
small workteams of Consultant Specialists of the different 
fields. It is only natural that those problems were dis- 
cussed first, which were most urgent according to the 
experiences made during the Eastern Campaign. 
Due to the difficulties of transportation, the great 
distances as a result of the extended frontlines of the 
different armies, and the frequently varying combat situations, 
only a certain portion of the Consultant Specialists could 
be invited to this Conference. As far as can be foreseen 
at present the same will hold true for future Conferences as 
well. The results of the discussions were laid down and 
directions for the different fields of work were derived 
therefrom. With the publication of the reports of this 
Conference the Commanding Medical Officers and all Consultant 
Specialists will be informed accordingly. 
This booklet contains suggestions in the field of 
medial science. Its distribution will not affect a change 
or supplement the leaflets (Army Manual 209/1 , Army Manual 
209/2;. In addition it must be pointed out, that no 
essential changes appeared to be necessary according to the 
results of this Conference. The results of the ’'Conference 
East" will be taken into consideration during the pre- 
paration of the new edition of these leaflets of the Army 
Manuals. The results of this Conference and the suggestions 
given in the discussions ought to be complied with from 
now on, if this does not involve any basic organizational 
changes. 
The Army Surgeons, Commanding Medical Officers as well 
as the Consultant Specialists have to direct their attention 
especially to the practical effect of the scientific results 
of this Conference. 
A small number of copies of this booklet is forwarded 
for the use of all larger hospitals. 
/s/ Dr. HAWDLOSBR Speech of the Army Medical Inspector. 
GentlemenI 
The first central war-conference of the consultant 
specialists took place on the 3rd and 4th of January 1940. 
It is of interest and necessary to repeat the subjects 
discussed in this conference: 
1* Wound-treatment, especially in case of injuries 
to the extremities. Infection of wounds# 
2. Blood-transfusion under field conditions* 
3» Injuries due to chemical warfare* 
4. Dysentery. 
5. Neurosis, psychopathy and organic diseases. 
6. Distribution of patients and problems of the 
evacuation of wounded* 
The lectures and the subsequent discussions were printed 
and distributed through the official channels, so that the 
results of the conference will become known to all medical 
officers. 
The Scientific Senate for the Army Medical Service in 
its session on 28 October 1940 dealt exclusively with the 
subject ”GaB*-gangrene” and the following problems have been 
discussed: 
a. Is gas-gangrene to be considered as a uniform 
disease with regard to prophylaxis and therapy? 
b. Is there any hope that chemical remedies will show 
prophylactic and therapeutic results? 
c. Prophylactic and therapeutic value of the gas- 
gangrene serum? 
d. lYhich prophylaxis and therapy should be applied? 
In a further session of the Scientific Senate on the 
2nd of December 1940 the problem of ’’prophylactic immunization 
was discussed and the following questions have been raised: 
a. Does a single prophylactic immunization against 
typhus promise the same success as three vaccinations' 
b. Is a prophylactic immunization against dysentery 
necessary, and which serum should be employed? 
c. Should an active immunization against tetanus be 
introduced? 4 
d# What is to be thought of the combined immunization 
- tetanus, diphtheria, typhoid, paratyphoid A and BV 
Since then the unsettled problems of importance have 
been discussed in numerous decenterialized field conferences 
in the area of the array surgeons and commanding medical 
officers of the occupied territories, and new experiences 
have been added. In a continuing series of leaflets the 
status of the results of these experiences is being made 
known to all medical officers* 
If from many sides the objection is raised that the 
mass of the medical officers is too little informed about 
the events in the field of medical science during this war, 
I wish to point out at this place that we have at our dis- 
posal a periodical which covers all fields of military 
medicine, namely the "Deutsche Militaerarzt" - the German 
Military Surgeon - to which every medical officer 
interested has access* He will find there the information 
about the basis of any problems to be discussed as well as 
information about the progress and change of the efforts to 
find the best solution. In addition to complete single 
reports there are always pertinent and complete directions of 
leading consultant specialists in all fields which are sup- 
posed to be a guide for all of the medical officers of the 
Armed Forces in the field as well as in the homeland# 
Something should be said about the often criticized 
censorship of scientific publications during the war with 
a limitation of the possibilities for publication# Anybody 
who is fully aware of what is going on knows how eagerly 
the enemy press abuses even the most harmless figures and 
statements concerning the state of health within our Armed 
Forces for the most intensive propaganda against us and 
our military strength without abstaining from severe dis- 
tension as soon as they believe to have found even a flicker 
of facts suitable to their purpose. In certain fields of 
prophylaxis as well as therapy it is rot the purpose of 
our publications, to help the enemy with our research work 
and thus to promote his military strength# This is the 
point of view from which I would appreciate your under- 
standing of the limitation of scientific publications, 
which is due only to the particularities of the conditions 
of war# The hitherto centralized censorship of scientific 
publications has now been turned over to the branch offices, 
the army surgeons and the medical officers in the military 
district headquarters in order to avoid or reduce any 
possible difficulties by a more close contact between the 
author of the article and the censor# 
The present war requires the employment of the utmost 
strength# I know that each one of us does his best and 
makes the utmost effort. In order to achieve this a close 
and parallel cooperation is first of all necessary, as well 
as a certain understanding for the limits of the humanly 
possible achievements, which limits have once and forever 
been set by the peculiarities of this war# In addition the 
limitation in a personal as well as in the material respect 
haVe to be taken into consideration. Critiques can only be 
useful if they are correct and based on experiences and if 
th$y are combined with suggestions which would lead to an improvement, however, these suggestions must be such that thej 
are practical. Criticism alone cannot lead to a progress 
and this is useless* However, we v/ill greatly appreciate 
any assisting cooperation as well as any useful advice* 
I shall heartily welcome such assistance into our circle 
so that the individuals may participate in the work and 
share the responsibility; 
I considered it useful and necessary to discuss these 
matters in principle* 
Since the First Conference of the Consultant Specialists 
held during this war it was no longer possible, due to the 
conditions of the war, to hold a second war conference of 
the same extent; 
For various reasons the number of participants of 
the present Conference East had to remain limited. Cn the 
one hand it was impossible to tc?.ke all consultant specialists 
away from the eastern front, on the other hand the directions 
referring to the limitation of traffic caused such unsur- 
mountable difficulties that it is impossible to bring 
about a meeting of a larger extent. As indicated in the 
title of this conference, modical scientific problems due 
to the eastern warfare have to be dealt with in principle. 
The course of this eastern campaign, the extent of 
Russian territory, the cultural level of the Soviet Union 
and her population, the comparatively scarce means of trans- 
portation in Eastern Europe and finally the hazards threaten- 
ing by always possible epidemics coming from the Asiatic area, 
and in particular the last Russian winter which^we have just 
overcome have in numerous cases confronted us with entirely 
different problems than was the case in earlier campaigns 
during this war. We have gathered a lot of experiences 
thereby, and as a measure of precaution they will have to 
be evaluated for the coming winter. 
We will now discuss the directions which will be^valid 
for this conference! In short discussions, dealing with 
the important factors only and disregarding all known facts, 
the examinations will be carried out along the following two 
lines* 
1, What is the present status of the problem concerned' 
2* Which measures and which new directions should be 
derived therefrom? 
I would greatly appreciate, that the results are put 
down in writing in the morning of the second day of this 
conference. 
If my predessor, the late Generaloberstabsarzt (Lieut; 
General (MC)) Prof* WALDMANN suggested the directive motive 
for the First War Conference of .the Consultant Specialists i 
to be the question; HWhat can I do to strengthen the militar 
power”, this applies equally to this conference* I wish to 
point out, however, that all problems are to be understood 6 
and dealt with in a purely scientific manner. Suggestions 
concerning the organization of the Armed Forces Medical 
Service can be made only as comments. The problems with 
which we are confronted as a result of the injuries due to 
cold require special attention with regard to the-preliminary 
work of the Army Medical Inspectorate. Therefore* the 
problem of injuries due to cold has been included in the 
program of all groups of specialists with the exception of 
the psychiatrists. 
Much was expected from the chemotherapy of wound infec- 
tions with regard to the administration of sulfonamides. 
Unfortunately the experiments performed thus far which have 
been numerous enough and were performed in various theaters 
of the war have never led to clear results. 
In contrast hereto very satisfactory results have been 
gained in the field of blood-substitutes. The'preserved 
blood serum developed by Oberfeldarzt (Lt. Col., HC.) Dozent 
Dr. LANG has proven to be very useful. We will do our best 
to see that this preserved blood serum will be available 
to the largest possible extent during all larger campaigns 
in the future. 
It was the psychopath who caused numerous and serious 
difficulties to the commanding officers of the troops 
and the medical officers in the field. No commanding officer 
of a unit likes to have a psychopath amongth his men. This 
is the reason why the psychopaths frequently reach their 
desired aim of getting away from the troops. 
Typhoid was of particular importance during the past 
winter in Russia for the work of the hygienist, the internist 
and even the surgeon. From the epidemiological point of 
view the clarification of the problem of infection caused 
by dusty fecal matter of lice has caused considerable concern 
among the physicians of the homeland as well as the numerous 
commanding officers of the troops. Statements have been 
made that any delousing is useless unless it is combined with 
a disinfection of the dust of fecal matter of lice# 
I am now going to discuss the important field of dis- 
infestation. During the hard winter campaigns it could be 
performed only very seldom among the advanced units; but 
even at those places latere delousing establishments have 
been set up, numerous errors have been made in spite of all 
orders issued previously. It is the important mission of 
the Consultant Specialists, particularly of the hygienists 
and internists to check on all delousing establishments for 
the troops and hospitals continuously and energetically. 
They have to assure a well-functioning and rapid disinfesta- 
tion from lice by consultation and direction, employing their 
full authority. 
In addition to the strictly professional problems of thl 
conference a number of miscellaneous lectures has been put 
on the program. The subjects of these lectures are of no 
less importance than other discussions, otherwise I would not 7 
have put them on the program. It is just the Consultant 
Specialist who makes any acquaintances within his army and 
who must always be fully aware of the fact that he is 
always responsible with his name and his authority for 
what he says. He should not limit his points of view 
and his statements to the actual field of medicine, but he 
should try to contribute his best to our victory in conversa- 
tions with medical officers and medical corpsmen as well 
as with troop-officers and men of other branches of the 
Armed Forces. The lectures which will be held on Tuesday 
afternoon will supply material and hints in this respect. 
Medical work cannot be directed by rigid instructions# 
In spite of this, however, certain instructions are nec- 
essary from time to time for the medical officers in the field 
and in hospitals, particularly with reference to public health 
problems# These directions must not be based on theoretical 
experiences but on practical medical experiences in the 
theater of operation. This is the reason. Gentlemen, why I 
have invited you to this conference and why I wish to hear 
your points of view. After all, you are coming directly 
from the armies. Everything you have reported during the 
campaigns has been evaluated so that it can be used as the 
basis of your lectures# 
In order to obtain a more intensive exchange of opinions 
among the Consultant Specialists of the different armies I 
have planned to publish short circulars in the future which 
will have been prepared by my Consultant Specialists from 
the reports of the Consultant Specialists of the different 
armies and the commanding medical officers. They will be 
distributed as promptly as possible. 
At the end of my speech I wish to call your attention 
to an experience made during the past winters 
When the cold of the winter and the enemy action in- 
creased more and more, some soldiers showed a more considerable 
desire of managing to get back home. We were not always in 
a position to direct them along such lines into which they 
should have been directed. I realize that the conditions 
were harder in those days than some human beings could endure. 
As a matter of prevention, however, we, the physicians, have 
to accept the attitude of a certain sternness^in such critical 
times of the war, which prevents the possibility that a man 
who is less interested in the service can get back home. The 
most difficult thing of this objective is to balance the 
emotional qualities with each other and I believe that even 
more exact rules and instructions will have to be issued in 
the future than was the case previously. It is 
mission of the medical consultants to educate our 
officers in the field in this sense. The frequently difficult 
decision between the human love and a military necessity, 
between medical ethics and military sternness has to be made 
with a willing responsibility. Two medical officers from the circle of the consultant 
specialists have been killed during the Eastern Campaign: 
Oberstarzt der Reserve (Colonel, MC., Reserve) Prof, SELIGER, 
Consultant Surgeon of the l?th Army was killed on the 6th of 
August 194-1) Oberstabsarzt dor Reserve (Major, MC*. Reserve) 
Prof* SOMMER, Consultant Surgeon of the 6th Army died suddenly 
on the 12th of October 1941 with the Field Army, 
We will always remember them as men who have always 
faithfully fulfilled their duty in addition to all those 
German medical officers who sacrificed their lives in 
Russia, in the Balkans and in Africa. Let us rise ih 
tribute to these soldiers* 
It is my desire to thank you, Gentlemen, for your 
faithful work in these hard times* If the lives of 
numerous wounded soldiers have been saved and if they have 
regained their health, if the outbreak of disastrous epidemics 
in the Army and in the homeland has been prevented, we can 
be proud of this success of the work of the German physicians. 
One will always find them ready and indefatigable, equipped 
with the best mental and material means to work for the 
sake of our fatherland. 
All knowledge, consultation and research work rill gain 
its full success and appreciation by action only* It is the 
purpose and the mission of this conference to pave the way 
for German science, and further it for the sake of our 
marvellous soldiers* I. 
AMPU T ATION TECHNIQUE 
Translation prepared by: 
Office of Military Government for Germany (U# S» ) 
Office of Naval Advisor 
Medical Section 10 
!♦ Amputation technique. (Abstract) 
Oberfeldarzt (Lt. Col,, MC.) Prof, FREY 
During World War I, the German military surgeons made 
too few and too late amputations. There is still no uniform 
opinion concerning the technique of amputation. Objections 
are raised against the flap method. Even the largest flap 
is insufficient for a complete covering of the stump. 
One is never able to perform a secondary suture. Amputa- 
tions in the field are made in order to save lives, and 
not to preserve a nice stump ready for prosthesis. In 95 
per cent of the cases a second amputattion has to be per- 
formed. Therefore the complete amputation has to be divided 
into two portions during the war: 
1. Into the live-saving amputation at the front, which 
will be performed at or slightly above the wound and 
2. Into the final stump-shaping secondary amputation, 
which will be made in the homeland under completely 
quiet conditions. 
FREY recommends the method saving most lives and most 
material. 
Discussion: 
KRUEGER: Agrees with the opinion of'FREY to perform the 
amputation at or slightly above the wound. 
PSIPER: Expressed his hesitancy to approve the method 
of FREY to perform the operation at the wound because of 
the destruction of the soft parts and the danger of an 
anaerobit infection. 
KILLIAN: Fully agrees with the principal of FREY. 
FRUEND; Agrees with an amputation at the wound. The 
amputation method of KALANDER is very suitable in case of a 
suspicion of gas gangrene, as it does not involve any large 
transverse incisions of the muscles. 
GULEKE* If flaps should remain, they can be turned 
toward the outside. In general a conservative treatment 
should be applied in case of amputations due to injuries 
resulting from injuries due to cold. 
ZIAJA: No far reaching generalizations should be made 
as a result of the catastrophic conditions of the winter 
campaign of this year. WACHSMUTH: Agrees fully with the principles of FREY. 
The major principle of the field amputations is economy. 
The problem of flap-incision or circular-incision should 
not cause any quarrels. The method of incision depends 
solely on the indication and the individual case. It is 
always wrong to enforce the execution of a method according 
to the procedures of a certain shool.. One has to be even 
more careful in cases of frostbites. Demarcation has to 
be waited for. Should one wait for a complete spontaneous 
detachment? 
SAUERBRUCH: The damage to the vessels and tissues 
extends centrally far beyond the demarcation line. In 
order to avoid late necroses, the amputation should be 
delayed at least for 3 - 4- months. 
FREY? The Flrqgoff-stump is not as bad as is generally 
maintained. The scheme of the amputation should not be 
according to VERTH, but according to the principle !to save 
as much as possible". 
ENGELKE: Forefoot-stumps I VERTH neglected the 
Hrqgoff- and Chopart-stumps. VERTH*s method for prosthesis 
is good for permanent treatment. 
GULEKE; One should not judge the fore-foot stumps 
equally. Contrary to the Pirogoff-stump, the Chopart-stump 
for instance is absolutely useless. 
FREY: Dictated principles concerning the technique 
of amputation under field conditions! 
Directives; 
It is the task of the field surgeons: 
1. to preserve the life, 
2. all the material possible, that is important for 
a later treatment of the stump, should remain* 
It is not the task of the field surgeons to form so- 
called stumps ready for prosthesis. The best method of 
amputation for the field surgeon is to amputate the ex- 
tremity at the wound or slightly above the wound* If the 
zone of destruction is situated near the joint exarticulation 
should be considered because of the danger of a subsequent 
empyema* It must be clear that almost every primary amputa- 
tion performed in the field requires a subsequent amputation. 
This fact must be taken into consideration during the first 
wound treatment. Therefore it does not mean much if the 
stump looks somewhat ugly at the beginning and if useless 
or hindering remnants are left which are of no use for a later 
adaptation of a prosthesis. The final shaping 
of the stump is a matter of the second ‘‘amputation wnich as 
a rule is performed in the homeland. During this operation 
the rules of peace time surgery will be followed. The problem of the front-line surgeon therefore does not con- 
sist of the question of whether or not he should apply 
the flap-incision or the circular-incision during his 
amputation. In case of a primary use of either of these 
procedures too much would have to be sacrificed in case 
of an amputation performed according to peace time rules. 
In every other respect the amputation at the wound is 
performed according' to the rules of the surgical treatment 
of wounds in war, i.e. tissue which will no more recover 
will be removed, caverns and pockets will be opened widely. II. 
GUNSHOT INJURIES OF THE BRAIN 
AND THEIR TREATMENT „ 
COOPERATION BETWEEN NEUROL 0 G I S T S 
AND SURGEONS. 
Translation prepared by: 
Office of Military Government for Germany (U* S* ) 
Office of Naval Advisor 
Medical Section 1* Gunshot injuries of the brain. (Abstract) 
Oberstabsarzt (Major. MC.) Prof. TOENNIS 
The speaker is in favor of the directions for an early 
treatment in effect since 1915, in contrast to the fatalistic 
conservative opinion of BERGMANN which can still be found. 
In addition he favors the closed treatment, the complete 
curettage of all hematomae and splinters, close suture of 
the dura along with a periosteum-galea-flap plastic operation 
during the first days. The decisive question during the 
operation is whether or not the dura has been opened, and 
whether or not a prolapse exists. All patients with a 
primary prolapse who received no treatment wall die* In 
general the infection will remain limited locally in cases 
without a prolapse. 
2» Concerning the cooperation with the neurologists in 
~ case of i:he treatment of soldiers suffering: from 
gunshot injuries of the brain* 
Oberstabsarzt (Major, MC.) Prof. v, STOCKERT 
As regards the problem of a cooperation of the neurolo- 
gists during the surgical treatment of soldiers suffering 
from gunshot injuries of the brain, it appears to be desirable 
to have a neurologist in charge of such wards of a field 
hospital, where the larger portion of the patients consists 
of soldiers suffering from these injuries. These patients 
should if at all possible be separated from the rest of the 
wounded. The majority of the extremely busy surgeons will 
welcome this suggestion# In case of open injuries of the 
brain it is indicated to perform the operation immediately 
so that in this case the advice of the neurologist will hardly 
be necessary# In spite of this fact, however, he should be 
present during the operation and if he is sufficiently 
qualified should assist the surgeon# The first decisive 
question which rises usually is whether or not the dura 
should be opened in case of a tangential gunshot wound 
which has affected the bone only but which has left the 
dura uninjured. In spite of the feet that the surgeon will 
in general feel very little inclination to open the dura 
because of the danger of an infection, this will be indicated 
in most cases where the focus of destruction located under- 
neath the dura has led to clear focal symptoms during the 
first hours. This is the first opportunity where the neuro- 
logist will have to express his opinion which will be 
decisive for the operation. His principal mission, however, 
is a critical observation of the clinical course during the 
first days particularly as differential-diagnostic difficulties 
will occur in this respect# A subsequent hemorrhage can be 
the indication for a second operation in case of a primarily 
treated open gunshot injury of the brain or it can indicate 
an opening of the capsula of the skull in case of a closed gunshot injury of the brain# As these operations involve 
a new particular hazard for the wounded, the indication 
should be given only after a most careful consideration 
in order to avoid any errors* It is the exact clinical 
observation of the patient which is decisive in this 
case# In order to be able to perform these exact clinical 
observations, however, an exact knowledge of the so-called 
physiologic range in the field of symptomatology of fresh 
gunshot injuries of the brain is of importance* 
It is known to us by peace time surgery that HOETTGEN, 
SELBACH and myself were able to prove in the neuro-surgical 
clinic of TOENNIS at Wuerzburg that serile inflammatory 
reactions have arisen subsequent to an operation of the 
brain performed with all aseptic precautions* These in- 
flammatory reactions have caused a swelling of the brain 
and have become evident in the form of an organic dis- 
turbance of consciousness which increased as far as a Heep 
stupor (profound sleep, unconsciousness). This status has 
reached its peak after forty eight hours and has subsided 
again after three to four days* In case of open injuries 
of the skull this corresponds to the fact that the wounded 
soldier frequently has to walk to the advanced dressing 
stations with his gunshot injury of the brain and frequently 
with a considerable prolapse# Upon reception to the 
hospital and also later on he is able to remember all de- 
tails of his being wounded, however, he himself states 
that he lost consciousness during the evacuation in the 
ambulance car on the bed Russian roads# It is not seldom 
that a soldier suffering from an injury of the skull 
arrives in a pretty well informed state, becomes confused 
after a couple of hours, and shows a completely apathic and 
disinterested clinical picture on the next day* The wounded 
do not talk, they must be fed and they discharge urine and 
fecal matter unconsciously. Consciousness is regained only 
after several days and a lapse of memory of the events during 
these days will remain. In spite of a successful removal 
of a bullet, a bone splinter and of destructed tissue remnants 
this clinical picture will develop with an increasing and 
decreasing course# Therapeutic measures can consist of 
drainage (entwaessernde Massnahmen) injections of glucose 
and even of intramuscular injections of Salyrgan in case 
of a dangerous swelling of the brain. During the dysentery 
epidemic the drainage effect of the diarrhea was particularly 
impressive which has led to reduction of these marked pro- 
lapses# A sudden and unexpected change of an apathic clinical 
picture into an excited hallucination has to be considered 
as a particularly unfavorable symptom# The wounded man 
becomes restless, he wants to leave his bed, is frightened 
and shows the typical symptoms of hallucination# With the 
greatest probability all these symptoms indicate the onset 
of a meningitis which frequently results in an accumulation 
of pus in the base of the skull and thus causes an irritation 
in the area of the hypothalamus. The interruption of the 
apathic syndrome frequently is the initial symptom, although 
macroscopically a completely clear liquor can still be proven, 
even if microscopically a distinct increase of the number of 
cells has already been observed# If one succeeds in keeping 
the meningitis under control by an intensive sulfonamide 
treatment and by repeated careful lumbar puncture, this state 
of excitement will be replaced by the apathic syndrome which 
in turn will subside slowly. Finally I want to mention the occurrence of focal 
symptoms during the stage of congestion of the brain, which 
are already known to us from the clinical pictures follow- 
ing operations on the brain. Thus for instance we have 
observed aphasic disturbances in speaking (aphasia) in 25 
per cent of the patients in our hospital, which can be 
subdivided into 20 per cent motor and 5 per cent sensory 
aphasiae. While we could observe a direct injury of the 
left temporal lobe in many cases of a sensory aphasia with 
an impaired understanding of speech, we have observed a 
real injury of the left frontal lobe of the brain in only 
25 per cent of all cases of motor aphasia with inability 
to articulate. In 25 per cent of the cases the motor 
aphasia could only be considered as a secondary symptom 
of the brain congestion. This means practically that a 
sensory aphasia must always be considered as a symptom of 
a direct injury of the left temporal lobe, while the motor 
aphasia has no such local significance. The reason for 
this must be seen in the particular liability to congestion 
of the frontal brain which functionally gives rise to 
temporary focal symptoms. 
Taking into consideration the limited amount of time 
which is at my disposal, I wish to mention these few ex- 
amples only and to demonstrate that an expert evaluation 
of the clinical symptoms of patients suffering from injuries 
of the brain may give valuable advice to the surgeons, who 
are fully occupied with their surgical activities. 
Another decisive problem is the question in how far 
the cooperation of the neurologists may be decisive for 
the later fate of the patient suffering from an injury of 
the brain. Everybody who had to consult and to evaluate . . 
numerous cases of patients with injuries of the brain years 
after the incident, knows what it means, if practically 
nothing is said in the first hospital reports about the 
course of the clinical picture during the first weeks follow- 
ing the injury of the brain, and if only some single par- 
ticularly obvious symptoms, such as for instance a hemiplegia, 
are mentioned. There will hardly be a patient with a brain 
injury who will not file a request for pension rights at a 
later time. If we must then more or less rely upon the 
statements of the patient himself who had lost his memory 
for the decisive period of time, a certain unfairness is 
just as unavoidable as the fact that one or the other 
hysterical case, or individuals eagerly hunting for pension 
rights, will be granted more than their justified share. 
This applies in particular to cases of closed injuries 
of the head, such as conditions resulting from being buried 
or damages to the nervous system due to contusion and ex- 
plosions. In these cases we will frequently observe symptoms 
where the decision whether we are dealing with an organic 
or a functional disturbance will be particularly difficult 
from the beginning on and where only an expert treatment 
can avoid that functional symptoms develop following an 
original organic damage which in the final analyses will 
not permit a separation of these components. It is the 
particular merit of Stabsarzt (Captain, HC.) Prof. BETZENDAHij 
to have called attention to these temporal organic symptoms 
in case of clinical pictures of a pseudo-neurasthenic 
character. It is only natural that on his way from the frontline 
to the home hospital the patient will be treated by different 
physicians. This fact is particularly unfavorable in the 
case of patients suffering from injuries of the brain where 
organic and psychological factors exist simultaneously and 
where every change in treatment and every different evalua- 
tion of the disease of the patient will always be clearly 
recognized and influence the patient!s attitude* I there- 
fore want to direct your attention to the question whether 
or not j t would be worth while to establish an immediate 
relationship between the special wards for patients suffer- 
ing from brain injuries in the field hospitals and the same 
wards in the home hospitals, as is the case with the corre- 
sponding special hospitals of the Airforce* In this way 
a uniform method of evaluation and treatment will be 
guaranteed which undoubtedly will have a favorable effect 
on the objective and subjective status of the patient with 
a brain injury. 
Discussion: 
WACHSMUTH: Three points of discussion: 
1# Trepanation must be made in the slightest 
injuries of the brain, 
2, All fragments must be completely removed, 
3, Should the operation be performed by a frontal 
approach? Is a localization by X-ray essential? 
TOENNIS: I am able to operate a clearly depressed 
injury of the skull without localization by X-ray, I am 
not able to do so in case of a missile lodging in the de- 
pressed skull. 
PEIPEH: Suggests consulting otologists to get acquainted 
with the technique of otology. 
GULEKE: An aspirator is absolutely necessary. Speaker 
is presently engaged in the development of such an apparatus. 
FREY: Where should gunshot injuries of the brain be 
operated? At the place where the first surgeon can be found 
who is able to perform this operation? 
WUTH: At what time should a neurologist be consulted? 
1, It is impossible and unnecessary to have a neuro- 
logist in every hospital. 
2, It is impossible that the consultant neurologist 
goes to advanced points to cooperate‘with some 
surgeon who has a certain preference, 
3, Difficulties have been observed in the rear establia- 
v; „ ments. This is the place where the consultant 
specialist is needed in order to avoid a repetition 
of the events of 1918, 18 
I wish to call your attention to the importance of the 
problem of psychopaths as well as to the forensic evalua- 
tion of such cases* 
CHRISTUKAT: Patients who once suffered from an injury 
of the skull later on believe they had an open gunshot injury 
of the brain, even if no neurological finding was made. The 
situation is entirely different in case of closed injuries 
to the skull. 
Kurt SCHNEIDER: Is of the opinion that a neurological 
examination of patients suffering from gunshot injuries of 
the brain is first of all a matter of the surgeon* A co- 
operation of the neurologist will not be so valuable with 
regard to therapy, but it will be appreciated* 
WUTH: Psychiatrists will be consulted in order to 
avoid the confusion of 1918* They should not perform their 
duties as assistants of the surgeons or as physicians with 
general duties. Their mission should also not only consist 
of the collection of scientific material* Their principal 
mission is to give consulting advice to the Army Surgeon 
or the Surgeons of Military Districts in all important 
problems referring to psychologic education of the Armed 
Forces, problems of psychopaths, and to act as consultant 
specialists in all matters pertaining to forensic medicine, 
as well as to take care of the assignments of psychiatrists 
and neurologists. 
Kurt SCHNEIDER: There is no problem of psychopaths 
during mobile warfare* There will however be numerous 
cases of gunshot injuries of the brain and of the nervous 
system for the treatment of the neurologist may give 
valuable advice. 
Carl SCHNEIDER: The number of secondary diseases can 
be reduced by the cooperation of the neurologist* The number 
of hospitals for the treatment of patients suffering from 
injuries of the brain is insufficient. 
Most important sequelae of these injuries are: 
1* Postinfectious conditions; 
2* Prolapses; 
3* Sequelae similar to brain abscesses; 
4* Vegetative sequelae* 
In case of an early and expert treatment there is the 
possibility of a reduction of these sequelae. Furthermore 
there is the possibility of a reduction of the number of 
epileptic cases. As long as no operation has been performed 
on the patient suffering from an injury of the brain, his 
evacuation is relatively simple. 
After the operation the patient suffering from an injury 
of the brain must rest in bed for 3-4 weeks* Sometimes it will be better to not perform an operation 
immediately, but to allow the patient to rest in bed for 
24 hours5 his condition will then improve# 
it will be hard for the patient to endure an evacua- 
tion of 80 - 100km# in an ambulance car# It will be re- 
latively easy for him to endure air evacuation, with the 
exception of cases where he is exposed to the low pressure 
of high altitutes# 
A primary treatment about 100 km# behind the frontline 
will essentially improve the result of the entire treatment. 
Fewer prolapses will occur in case of a carefully performed 
operation. In all cases of gunshot injuries of the brain 
where no careful curettage has been made during the primary 
treatment subsequent prolapses will be observed# it is im- 
possible to establish a special hospital for the treatment 
of injuries of the brain everywhere. 
The course of the clinical picture of a patient suffer- 
ing from a gunshot injury of the brain should be subdivided 
into 4 to 5 different phases of treatment in order to 
facilitate the work of the surgeon. 
1# Phase where the patient has not been given any 
treatment. 
2# Phase following the primary operation (with 
curettage or with a simple trepanation)# 
3* Actual process of healing of the wounds# 
4# Phase following the covering of the wound (by 
suture, scar-formation). 
The surgical treatment should preferably be performed 
during the second and third phase# During this period of 
time the patient should remain in surgical wards as far as 
possible# 
During the first and last phase the advice of the 
neurologist and the psychiatrist should be decisive# 
Surgeons perform a very systematic^work, but they 
frequently do not consider the pathological sequelae sub- 
sequent to the injury. The value of the different symptoms 
is not taken into consideration, therefore a cooperation of 
the neurologist and the psychiatrist is very important in 
order to avoid late sequelae. 
It was the surgeons who showed which cases they should 
better not treat, (fixed pupils, lesions of transverse in- 
cisions) • 
Serious injuries of the brain stem should not'be treated 
surgically, because of the too high mortality rate# In the 
homeland the crux of the situation is this: Many patients 
suffering from injuries of the brain are treated too late 
by the neurologist and the psychiatrist# They remain in 
surgical wards for months without being treated by work- 
therapy# All paralyses should be fixed. Symptoms of in- 
sufficiency will be observed. 20 
The third phase (actual process of healing of the 
wounds) should be completed as soon as possible and the 
patient should be transferred to a hospital for patients 
recovering from injuries to the brain (work therapy). 
A cooperation between surgeons and neurologists in the 
advanced hospitals should be obtained. 
Summary: 
WUTH: 1. Problems of evacuation, and organization 
are not subject to discussion by the consultant specialist. 
2. The consultant specialist of an army cannot 
possibly be kept in a field hospital. He can consult 
neurologists and assign them to field hospitals but he 
must never lose the control over all the establishments 
under his supervision. 
Responsibility for the psychological status of the 
Armed Forces must bo carried by one man. 
Sequelae following injuries of the brain should be 
dealt with in the hospitals in the homeland. 
It has been pointed out often enough, that surgeons 
need to consult psychiatrists and neurologists. 
Directions for the treatment of patients suffering 
from injuries of the skull* 
It will be most useful to subdivide gunshot injuries 
of the brain according to the clinical points of view into 
the following groups. 
1• Gunshot injuries with the bullet passed 
"Through the skull. 
1* Depressed fractures of the skull caused by gunshot. 
a. without an opening of the dura, 
b. with opening of the dura and without prolapse 
with prolapse. 
2. Gunshot Injuries of the skull with the bullet 
lodging inside# 
3. Gunshot injuries of the skull with the bullet 
passed through the affected part# 
II. Gunshot injuries affecting the base of the 
skull. 
1. Depressed skull-fractures due to gunshot injuries, 
a. without an injury of the dura, b. with an injury of the dura* 
2. Gunshot injuries with the bullet lodging in the 
base of the skull* 
3* Gunshot injuries with the bullet passed through 
the base of the skull. 
All patients with gunshot injuries of the skull should 
be evacuated as quickly and as carefully as possible to 
the special wards where a neurologist can be consulted 
and where treatment can be performed. An exception should 
be made with those patients who are unable to endure an 
evacuation due to severe comminuted fractures of the skull 
due to gunshot injuries. They should be evacuated, to 
the next main-dressing station or field hospital. In all 
cases where the general situation renders this impossible, 
the fresh gunshot injuries of the skull must be treated 
by the surgeons of the advanced medical establishments* 
Under no circumstances may cases which promise success 
be kept in the advanced medical establishments because of 
difficulties with regard to evacuation, which will thus 
miss an early surgical treatment. 
In every case those patients must be treated surgically 
in the advanced medical establishments, who show symptoms 
indicating danger of life (increase of cerebral pressure). 
These symptoms are increasing unconsciousness,change of 
the pupils with regard to their width and reaction* decrease 
of the pulse rate with subsequent acceleration* The only 
cause of such cases of an increase of the cerebral pressure 
within the first 48 hours is arterial hemorrhage which 
occurs only with depressed skull fractures due to gunshot 
without prolapse and skull injuries with the bullet lodging 
in the affected part* 
To judge this it will be necessary to: 
1. Observe the patient at least for several hours; 
2* To find out whether the condition of the patient 
will improve after an intensive treatment with 
infusion of glucose, or with remedies to stimulate 
the peripheral circulatory system* 
This indicates clearly that a patient suffering from 
a gunshot injury of the brain must not be operated immediate! 
after evacuation, but that he has to be put under observation 
at least for some hours. In principle the 48-hour limit 
should be adhered to as observation period. Exceptions 
should be made in cases xvith a prolapse because their out- 
come will be fatal anyhow7, although the prospects are much 
worse in those cases. 
If at all possible X-rays in'two planes should be made 
before each surgical treatment of gunshot injuries of the 
skull. It is recommended that a lumbar puncture (20 ccm.) be 
performed before the operation in order to reduce the 
pressure of the spinal fluid. 
During the further course the lumbar puncture, which 
serves to reduce the high cerebral oressure with a cerebral 
prolapse can bring essential relief, if an increase of the 
quantity of spinal fluid was the cause# 
The object of the primary surgical treatment of the 
wounds is to: 
1, clean the cerebral wound from fragments of the 
missile, remnants of tissue and germs causing 
an infection; 
2# arrest hemorrhages; 
3. avoid secondary infections# 
In principle this is achieved by a debridement of the 
external wound, widening of the bone-gap, aspiration of 
the wound contents from the brain and careful application 
of hemostasis. After this, covering the gap in the hard 
cerebral membrane (closing the gap by pedunculated flaps 
of galea-periosteum freed laterally) and a tension-less 
suture of the skull-cap in layers, if necessary by means 
of flap-plastics# During this operation on • the one hand 
one must assure the most thorough removal of all remnants 
of tissue from the wound (as the wound will reopen other- 
wise, eventually with a secondary cerebral prolapse) and on 
the other hand for a completely tension-less closure cf the 
external wound. To achieve this, sulfonamides can be ad- 
ministered either orally or intravenously. For the 
elimination of pains local anesthesia with or without the 
administration of S.E.E. will be applied. If the patient 
is very restless, Evipan-narcosts can be given. 
The cleaning of the cerebral wound, is done best by 
aspiration. If this is impossible there is no other choice 
than to use the catheter with a syringe cr soft curettes 
or grasping foreceps, which must naturally be used as 
carefully as possible# Most suitable for the arrest 
hemorrhages are the silver-clips or coagulation. If this 
proves to be impractical, pieces of rruscule tissue may be 
sewed in place. In case of sinus-hemorrhages it is re- 
commended to perform a ligature around or sewing in place 
of pieces of muscule tissue. The best means to arrest 
hemorrhages of the bone is to apply sterile wax# Every 
hemorrhage has to be arrested before closing the wound. 
If the location of the wound suggests a sinus-hemorrhage 
an interference with the possible place of injury of 
sinus should as a measure of prevention be avoided. During 
the widening of the bone-gap, the fragment lodging in the 
sinus should be removed first, if the piece of muscule 
tissue necessary for the closure is already at hand# The uninjured dura should not be opened in case of 
new injuries* This may only be done if it is strictijr 
indicated because of an increase of the cerebral pressure 
due to hemorrhage* This happens very rarely* 
In case of apparently superficial gunshot injuries, even 
with the smallest wounds, a thorough debridement of the wound 
must be performed. This should be preceded by an X-ray 
examination if at all possible. An intact lamina externa 
does not exclude an extensive fracture of the lamina interna. 
Sven the smallest wounds in the skull may perforate and may 
show serious sequelae as a result of gunshot injuries into 
the brain. 
In case of gunshot injuries of the base of the skull 
the participation of the accessory sinuses is of particular 
importance (danger of infection). In this case a curettage 
of the affected accessory sinus, a thorough and clearly 
visible exposure of the wound of the dura, the usual debride- 
ment of the cerebral wound and thereafter a particularly 
careful closure of the dura from the accessory sinuses must 
be made by a pedunculated flap of galea-periosteum* A good 
drainage from the accessory sinuses has to be provided 
routinely. 
After the operation a period of rest in bed of possibly 
4 weeks must be striven for. 
In case of an additional meningitis an improvement can 
be achieved by an operation, if the focus from which the 
meningitis originated can be eliminated. In addition to the 
local surgical treatment, lumbar-punctures v/ith a gradual 
insufflation under evipan-narcosis with the patient in a 
half-bending position has to be performed. In addition 
sulfonamides shall be administered as well as drugs stimulat- 
ing the circulatory system. In case of a progressive 
encephalitis no improvement can be expected. 
All details are contained in the "Directions for the 
treatment of gunshot injuries of the brain" in the collection 
"The troop physician", volume 6, J. F. Lehmann edition 
Munich-Berlin (Rlchtlinien fuer die Behandlung von Schuss- 
verletzungen des Gehirns" in der Sammlung "Der Truppenarzt", 
Band 6, Verlag J. F. Lehmann, Muenchen - Berlin)* III. 
THE TREATMENT OF FBESH WAR WOUNDS 
BY CAUTERY 
Translation prepared by: 
Office of Military Government for Germany (U, S. ) 
Office of Naval Advisor 
Medical Section 1. Short survey concerning the development of this method. 
Oberfoldarzt (Lt. Col.. MC.) Prof. WACHSMUTH 
The contradictory opinions of many specialists in this 
field induced the Army Medical Inspector to prohibit for 
the time being the application of the cautery method in 
the field. The Army Medical Inspector now requested the 
surgeons present at this conference to express their final 
opinion on this subject. 
2. Success and effect of the treatment by cautery, 
Stabsarzt (Captain, MC.) POECK 
The speaker has reported about the success and the 
effect of the treatment by cautery. These reports were 
based on his experiences with 4 000 patients of 1 division 
treated by this method. Only in 235 cases can an exact 
survey be given. 7 of these ended fatally. As the 
principle advantages of this method which POECK docs not 
consider as a substitute but only as a supplement of the 
surgical treatment the following factors are emphasized 
by him. No spreading of germs, hyperemia, constant 
sterility of the instrument, increase of immunity. 
Damages by decay of protein are of no importance, the 
same holds true for acidosis. POECK strictly resents 
the assertion that the crust due to the cautery treat- 
ment could have an occlusive effect; he recommends to at 
least test this method of treatment in some special 
hospital wards. 
Discussions 
ROSTOCK: Equal mortality rates were observed in 400 
cases of animal experiments with and without cautery. 
Within the 6th Army the cautery method has been used in 
486 patients, but in only 5 per cent of them there was an 
improvement recognizable. The method remains valid for 
the treatment of phlegmons and abscesses as mentioned 
originally by BIER. Its application is resented for fresh 
war wounds. 
KILLIAN: The figures mentioned by POECK are of no 
importance, as they arc based on observations made in 'the 
area of scatter" (Streuungsbereich). 6 cases of gas 
gangrene subsequent to cauterization have been observed. 
The speaker rejects the method. 
KRUEGER: Is in favor of the cauterization method only 
in case of beginning phlegmons and abscesses but not in 
case of fresh war wounds. POECK: By the application of the cautery the con- 
tinuation of an active surgical intervention inside the 
wound is obtained. The speaker differentiates between 
a prophylactic and therapeutic application of the cautery. 
WACHSMDTHs The problem of using the cautery method 
can only be discussed as far as its use in case of fresh 
war wounds is concerned. An accumulation of negative 
opinions can be observed. The speaker dictated a de- 
claration according to which the specialists present 
agree with the decision of the Army Medical Inspector 
to prohibit the application of the cautery method# The 
method will remain permissible for the treatment of 
abscesses and phlegmons. 
Points of vie**7. 
The surgeons present at the Conference East are of 
the opinion after hearing the lectures of Dr. POECK, that 
according to the present status of experiences the use of 
cautery in fresh war wounds is under no circumstances so 
safe that its application would be permissible in the 
field. 
As far as its application in the field of septic 
surgery, and in case of abscesses and phlegmons in reserve 
hospitals is concerned the method will remain permissible 
in such cases where it is indicated. 
The surgeons therefore agree with the decision made 
by Army Medical Inspector dated 10 January 1942# IV. 
CHEMOTHERAPY OF THE WOUND 
INFECTIONS 
Translation prepared by; 
Office of Military Government for Germany (U* S. ) 
Office of Naval Advisor 
Medical Section Chemotherapy of the wound infections• 
Oberstabsarzt (Major, MC.) Prof* ROSTOCK 
Chemotherapy of wounds hr.been known for ages. Every 
war has changed the old problem and raised it again accord- 
ing to the state of scientific knowledge. 
/ 
This lecture is not supposed to be an account of the 
experiences gained up to this date, but it is supposed to 
be a summary of what we know as a result of our daily 
practical experiences, and this shall be the basis for a 
discussion. 
With regard to the administration of sulfonamides 
which are now in the center of interest, it is new that 
primarily they were not applied locally on the wound but 
that they were administered to the body in general either 
in an enteral or parenteral manner 'and that thus they de- 
veloped their effect. In addition it is new that some 
preparations are specific against different kinds of 
bacteria and the diseases caused by them. The results of 
a sulfonamide treatment are uncontestable in case of 
pneumonia, gonorrhea, epidemic meningitis and perhaps in 
case of erysipelas. However, we do not want to discuss 
those diseases at this time. This discussion is to be 
limited to infections of wounds, (tetanus, gas gangrene) 
and suppurative wound infections. 
It is known to us that sulfonamides are ineffective 
against tetanus. Their effect is disputable in ease of 
gas gangrene. No definite decisions have been made in 
this respect as yet. This may partly be due to the fact 
that genuine gas gangrene, which is caused by the three 
known exitants is not always clearly differentiated from 
the phlegmon with gas, the symptoms of which are in 
principle benign. 
As regards the treatment of wound infections it is 
the enteral or parenteral administration that is presently in 
the center of interest, but it is the local application. 
Different opinions have been expressed about the results 
obtained. BRUNNER even dared to treat contaminated peace 
time injuries locally with sulfonamides and then sutured 
them without performing a debridement of the wound* SCHREUSS 
has given too much praise to the far reaching effects of 
these remedies. KIRSCHNEH and his assistants expressed 
their doubts about their effect. They have tried to prove 
by experiments that Iodoform is superior to the sulfonamides 
in case of a local application on the wounds. 
The statements concerning the effect of these remedies 
are of the utmost importance for our medical standards. In 
the past one was in the belief that the remedies for the 
disinfection of the wounds must have a particular effect on 
the vitality of bacteria and one has arrived at the generally 
known conclusion that all remedies applied would sooner^lead 
to a decay of the cells than the bacteria lodging therein. Tho sulfonamides are said to have a different effect. It 
lias been asserted by HEUBNER that it is only inside the 
body tissue that the sulfonamides develop the effective 
substances, the exact nature of which is still unknovn. 
On the other hand it has been asserted that these remedies 
produce a socalled protective tissue inside tho wound. 
Other scientists are in the belief that the'remedies 
facilitate the phagocytosis of the bacteria. It is of 
importance to point out that necrosis of tho tissue and 
their decomposition products inside the wound hinder the 
effect of the drug. 
For their practical application it is of basic im- 
portance to find out exact details about the efficiency 
of the sulfonamides. Therefore fundamental research 
should be given the highest priority. I am able to create 
the material conditions for such research work in my 
clinic, if the necessary number of patients will be trans- 
ferred there and if suitable physicians with serious 
interest in such research work can be made available. 
It will be necessary for the collection of clinical 
experience that the different kinds of bacteria react in 
a different way. The prenarations have a bettor effect 
if they arc applied or administered in vivo than in case 
of an application in vitro (BRUNNER), With regard to their 
increasing power of resistance against sulfonamides the 
wound bacteria can be subdivided into the following groups; 
Pneumococci 
Streptococci 
Coli bacteria 
Proteus 
Pyocyaneus 
Staphylococci, 
The position of the most .important exitant of gas 
gangrene within these groups is disputable. 
If we attempt to find the purpose and the method of 
clinical experiments tAe following can be said in general: 
The most urgent problem appears to bo the examination 
of the efficiency of the sulfonamides in case of a local 
application in wounds. Under no circumstances, however, 
should the surgical treatment of the wound be forgotten in 
this case. It will always remain the basis of any treat- 
ment, also in case of an applied chemotherapy, for necroses 
in the area of the wound will essentially hinder the effect 
of sulfonamides. The principle danger of chemotherapy con- 
sists in the fact, that it may induce careless physicians 
to be less thorough during the debridement of the wound, 
due to a certain confidence in chemotherapy. 
Equal series can bo created by experiments, in other 
words exact research work can be done as has been demanded 
by KIRSCHNER in his controversy with SCHREUSS, In bed-side 
medicine the opinion of the experienced physician concerning 
the effect will be decisive. 30 
Secondly the effect of a remedy administered for the 
organism in general, must be tested. It is highly probable 
that the efficiency will be inferior to the method of a 
local application. The application through the general 
organism might be of a certain importance in case of in- 
juries of the brain, as there exists no limit of liquor 
of the blood in case of sulfonamides. 
During the discussion of the dosage it has been re- 
quested to make it dependent upon the concentration of the 
remedy in the blood (5 - 10 mg.per cent, in serious cases 
20 mg.) and upon its excretion in the urine* An exact 
knowledge of the facts might be necessary for scientific 
experiments. For a practical application in times of war, 
however, this criterion will be useless* We will have to 
search for more simple indications of the dosage* 
As in all other cases of administration of sulfonamides 
a sudden effect for several days must be obtained in case 
of a local application, and not a regular and continuous 
effect. After the revision of the wound we will dust the 
powder into the wound by means of a dust-sprayer (powder- 
atomizer) or salt-shaker* This will be repeated, on the 
occasion of the next change of the dressing. During the 
days between the change of dressing the remedy should be 
administered orally. A parenteral administration will be im- 
possible during the turmoil in war time* 
DOMAGK recommends the following method; 5-20 grams 
of Marfanil-Prontalbin-powjder should be applied (smeared) 
into the w/ound with about the thickness of a back of a knife- 
blade. If the powder is still dry on the surface of the 
wound at the time of the next change of dressing, considered 
less powder may be applied the next time, or its applica- 
tion nay be eliminated completely. 3 - 6 grans of Marfanil- 
Prontalbin in tablets will be administered during the days 
between the change of dressings. After 6-8 days an inter- 
val of about 1 week diould be made if possible* If necessary, 
the same treatment has to be repeated. It will be up to 
the physician in charge to determine the smallest optimal 
dosage fr each patient. 
A similar dosage scheme is effective for the administra- 
tion of Cibazol and Cibazol-boracic acid powder* 
Injuries due to the use of sulfonamides are rare. 
Slight inconveniences have been observed, such as: nausea, 
vomiting, cyanosis, diarrhea, tinnitus, and headaches. 
All these symptoms subside immediately after an inter- 
ruption of this treatment. In addition scarlet-!ever-like 
and bullous oxanthemae have been observed, furthermore a 
degeneration of the liver (Icterus) and injuries to the 
kidneys as well as neuritis. No definite fatal cases have 
become knowm hitherto. The treatment of all such injuries 
consists in an immediate interruption of the administration 
of these drugs, and under given circumstances in bloc cl - 
transfusions• 31 
We wish to discuss in short the particularities within 
the different regions of the body. 
Within the urogenital system the efficiency of the 
sulfonamides is argued about. It is definite, that the 
sulfonamides are less effective here than in case of 
ordinary wounds. In case of abdominal gunshot injuries 
and peritonitis a dusting of the sulfonamide powder into 
the abdominal cavity and into the wound on the abdominal 
wall is combined with an oral administration* In case 
of gunshot injuries of the joints BRUNNER has performed 
a rinsing of the joint cavities with a 2 - 5 per cent 
Cibazol solution and has filled the joint with this 
solution. 
In comparison to the efficiency of sulfonamides which 
still has to be explored, all other remedies are of minor 
importance only. Numerous different remedies have been 
recommended. Due to the fact that our stocks arc limited, 
•an application of tincture of iodine is in general ex- 
cluded. SCHREUSS recommended Hexamethylentetramin and 
urea .combined with Rodan. The traumatic "epidemic"^of 
this war offers us an opportunity to test the efficiency 
of these new remedies for the treatment of wounds in the 
form of different preparations of sulfonamides. It Is 
our duty to take advantage of this opportunity. 
Discussion: 
WACHSMUTH: The tests with sulfonamides arc still 
under way. Therefore no definite result has been arrived 
at as yet. 
KILLIAN: Has been designated to perform further 
critical work in this connection together with DOMAGK 
(gas gangrene, basic research, and so on). 
KRUEGER: Expressed a very favorable opinion on the 
prophylactic effect of sulfonamides, which is however, based 
only on clinical observations (gunshot injuries of the brain 
without meningitis? gunshot injuries of the lungs, without 
empyema; and so on) (5000 cases). 
I 
SAUERBRUCH: Criticizes the primitive opinions concern- 
ing the healing of wounds. During World War I one hoped 
to obtain the same results with Vuzin, Rivanol and so on. 
These remedies veil the surgical activity and lead the 
physician to negligence. These methods should, however, 
be tested very critically and the tests should bo up to 
the surgeons who master the field of general surgery. 
KILLIAN: It is our mission to tost whether: 
1. the clinical course of the wound healing was 
favorable after the treatment with sulfonamides, 
2. a suppuration has occurred simultaneously, 
3. it was combined with gas gangrene. According to KILLIAN1*? observations on 1339 coses on 
improvement could be observed only in 13*8 per cent cf 
these cases despite a generous evaluation. The applica- 
tion cf sulfonamides in case of gas gangrene is particularly 
unfavorable because oxygen is consumed. In four cases 
gas gangrene has been observed. These problems require 
a careful further study. 
FRUEND: Recommends the additional treatment with 
sulfonamides, due to the insufficient possibility cf the 
debridement of wounds in tines of war. Ho observed 74- 
cases for 6-8 weeks I He is in favor of an early ad- 
ministration of sulfonamides in the highest possible 
dosage. Up to 8 grams may be administered during the 
first day. An increased effect of sulfonamides is ob- 
tained by a combination with Cebion. 
WACHSMUTH: The judgement based on general im- 
pressions do not yet allow one to draw final conclusions. 
It will rather be necessary to continue with a careful 
examination of the therapy with sulfonamides based on 
accurately observed individual cases. 
KRAUS PE: In general I agree with the statements 
made by ROSTOCK. - Induced by the physician of our army 
Generalstabsarzt (Lieut. Gen., MC.) Dr. GUNDERLOCH we 
have performed a particularly extensive therapy with 
Mesudin within our army since August 1941, especially 
in case of gas gangrene. Thus we dispose of a number of 
observations where this remedy has boon applied porcrally 
as well as locally. It has been very suitable in these 
cases. In spite of this I wish to point out that it is 
net yot possible to form a final opinion concerning the 
effect of these preparations. As mentioned above, we 
have hoard some very enthusiastic opinions about the 
preparation and the therapy, but at several places whore 
partly good results have been reported to us, particularly 
by surgeons, it has become known to us that no success at 
all was obtained neither in case a local nor of a 
peroral use. It is impossible to survey these statements 
right from the beginning. In a large number of cases this 
is due to the fact that in case of gas gangrene we are not 
dealing with a genuine infection of a definite strain of 
bacteria, but that actually these are always cases of 
mixed Infections, while the use of the preparations avail- 
able is always indicated in case of a particular type of 
germs only. Thus for instance we want to mention the 
serum against symptomatic anthrax bacteria, which are of 
minor importance in case of a gas gangrene infection, 
while the FRAENKEL bacilli and the NOVY bacilli have to 
be considered first of all. An additional factor is^that 
wo have seen so little success in case of a puie application. 
of these preparations that we considered an immediate^inter- 
ruption of their use to be indicated, in order to facilitate 
an active surgical therapy right from the beginning on. 
As has been mentioned by ROSTOCK the most important result 
arrived at was the conclusion that in case of gas gangrene 
the surgical operation is and will remain the most importan* 
factor. I wish to report in brief only about the microscopic 
examinations of sulfonamide treatments as I do not yet have 
the results of bacteriological examinations* It is my 
impression that in numerous cases a very abundant leuko- 
cytosis can be observed. However, this is also true for 
cases treated in a different manner. 
CHHISTUKAT: As far as neurologists are concerned 
throe groups of diseases are of special interest, namely: 
the poliomyelitis, the different kinds of encephalitis 
and the different kinds of meningitis* With regard to 
the first two groups of diseases it should bo pointed 
out that chemotherapy was a failure in their case* In case 
of meningitis an exception has to be made as far as luetic 
and tuberculous meningitis are concerned* No effect will 
occur in case of the first diseases of the two just mentioned 
and in case the second disease the general changes are of 
such a high degree that no effect can bo expected any more* 
Concerning the different effect of chemo-thcrapy cn 
the various kinds of cocci it should be said in brief that 
Eubasin has the best effect on'meningococci .and pneumococci, 
while Prontosil and Cibazol should be given preference in 
case of streptococci. 
As has already been pointed out by ROSTOCK, the 
ability of the blood plasma to dissolve the sulfonamides - 
is very good. Thus, the drug should in general bo intro- 
duccd into the blood. The level in the spinal fluid will be 
equal as was observed in examinations with a constant spinal 
fluid loss. The latter experiments have been performed 
primarily in Italy. 
/in intralumbar administration of sulfonamides should 
under all circumstances be avoided. This is true for all 
preparations. Everything that has been written hitherto 
about a possible lack of vitamin Bq and a corresponding ad- 
ministration of this vitamin is so hypothetical that it is of 
no practical use. I wish to call your attention once more 
to the fact that even in case of treating meningitis with 
sulfonamides the ser"m treatment and repeated lumbar 
punctures must never be forgotten. Even besides the sulfona- 
mide therapy this treatment remains the method of choice. 
GINS: I wish to make a short contribution to the 
problem of chemotherapy based on our chemotherapeutic 
animal experiments. In experiments performed under my 
supervision we have observed that no definite effect was 
recognizable for any preparation which wc have used. 
Neither Prontosil nor Prontalbin have shown any character- 
istic reaction. In case of an administration of Morfrnil 
and Mesudin none of our animals survived the The 
same observation has been made in case of an administration 
of Sulfanil as well as Siren, the so-called new sulfonamides, 
which are manufactured by the German Hystier-Factories. 
With regard to the latter group it can be said in conclusion 
There are no prospects for a special effect in case of a 
local application in animal experiments. Finally new tests were made to find out some more 
details about Katoxin which has been recommended some time 
ago with great hopes. Katoxin is a preparation, the 
effect of which is combined from an oligo-dynamlc effect 
of silver and a protracted effect of oxygen. The first 
tests which were made by the Katoxin-Company themselves 
appeared to be absolutely hopeful. Later experiments which 
were performed by the test-team of the Katoxin-Company 
right here in the Academy and under my supervision, appeared 
to be also very hopeful and in addition supplied a very 
interesting contribution concerning the psychology of animal 
experiments. As a matter of fact the following observation 
was made during a series of tests, for which the Katoxin 
preparation has been used, partly marked with the letter A 
and partly with the letter D. Curiously enough all animals 
on which the A preparation was applied have survived the 
test, while those animals exposed to the D-tost died* 
(LaughterI) It oust be emphasized that such things dc 
happen. It was impossible to discover any kind of negligence 
in connection with the performance of those tests. V.e have 
checked on this subject carefully. The suspicion, that 
somebody could have cheated must therefore be eliminated, 
I want to cite all of this only as an example of how care- 
ful one has to be to obtain definite results. The experi- 
ment has shown that Katoxin has no different effect than 
other sulfonamides. 
If we are to make any suggestion we wish to say that 
it will in general be the same as has been made by the 
clinicians already; One must always consider the fact that 
a guinea pig is not the same as a human being. As far as 
the results of the tests have shown, no injury has to be 
expected in case of preparations wThich develop their effect 
in the tissue. It is therefore worth while to consider 
whether or not detailed experiments should be made with 
this preparation. With consideration of our points of 
view we could not recommend the use of a definite pre- 
paration in general, however, we could recommend a clinical 
tost in equal groups and with consideration of the state- 
ments made by ROSTOCK. If this is done, than it might 
possibly be observed that with certain methods of applica- 
tion or with certain groups of sulfonamides a success can 
be expected on one or the other case, perhaps also with 
Katoxin. I sh'uld advise to include Katoxin in such tests, 
naturally this should only be clone with the point of view 
that one does not expect too much from those tests right 
from the start. 
Directions concerning chemotherapy of wound infections. 
The treatment of war wounds with sulfonamide preparetic 
against wound infection appears to be successful. At 
present the following preparations are available in the 
medical supply depots: Marfanil-Prontalbin-powcler, Prontcs:'. 
tablets, Neo-Uleron-Albucid-tablets, Eubasin-tablets, Sulfa- 
pyridin-tablets, Cibazol-tablets and Eleudron-tablets, An outbreak of traumatic tetanus cannot be prevented 
by those remedies* For this reason tetanus-anti-toxin should 
be administered as previously* 
It is net definite whether gas-gangrene can be prevented 
by chemotherapeutics* The collection of further experiences 
in this field is particularly desirable. 
During the treatment of war wounds there should first 
of all be a surgical treatment of the wound, along with a 
removal of all decaying tissue and an opening of all pockets 
gf the wound. Thereafter the remedy is dusted into the wound 
in a dosage of 5 - 20 grams, according to the size of__the wound 
This will be repeated with each change of dressing* Inde- 
pendent of the time of the change-of dressings tne patient 
will be given the following quantities of a sulfenamice pre- 
paration: per os (if necessary rectally or intravenous): 
8 grams during the first day, 6 grams during 2nd day, 
5 grams during the 3rd day, and 4 grams during the 4th to 6th 
day* The administration of these drugs should bo equally 
divided over the whole day* Thereafter the treatment with 
these medicaments should be stopped and it should only be 
started again if indicated* The earlier the treatment will 
be started, the better will be the prospects for success. 
It is recommended that the local treatment be per- 
formed. with the sulfonamide powders which are available 
along with an internal administration of such preparations 
as Albucid, Cibazol, Eleudron, Eubasinun, Globucid (par- 
ticularly in cases of gas-gangrene), Marfanil-Prontalbin 
and Prontosil. 
If secondary symptoms occur in some rare cases, such 
as nausea, vomiting, diarrhea, tinnitus, headaches, exzemas 
on the skin, or icterus, the treatment with these drugs has 
to be stopped immediately. V. 
EVACUATION OF THE W OUND ED 
Translation prepared by: 
Office of Military Government for Germany (U. S* ) 
Office of Naval Advisor 
Medical Section Evacuation of the wounded. 
Oberfeldarzt (Lt. Col.. MC.) Prof. WACHSMUTH 
Gunshot injuries of the extremities have to be treated 
in such a way that evacuation is possible at any time; 
that means that a plaster cast with a splint has to be 
applied or a plaster cast with traction maintained by a 
wire incorporated in the cast. The application of the 
extension method is in general rejected for use under 
field conditions. The use of the KUENTSCHEH marrow nail 
was unanimously rejected for field conditions. 
1« Medical indications far evacuation. 
The more unfavorable the external conditions for an 
evacuation are at the place of the surgical treatment 
(weather conditions, road conditions, means of trans- 
portation) the nrore carefully the medical indication for 
evacuation must be made. In case of poor evacuation 
conditions, an evacuation should be made only in case of 
a military or medical tactical necessity! 
An early evacuation has to be avoided if at all 
possible in case of gunshot injuries of the skull, lungs 
and the abdomen. As a rule, these patients require 3 
weeks of rest in bed after the surgical treatment. 
2. Guarantee of the possibility of evacuation 
at any given time. 
In case of unstable field conditions (information 
should be obtained regularly concerning the tactical 
situation!) the wounded have to be treated in such a way 
that they can be evacuated at any given time. As'far^as 
gunshot injuries of the extremities arc concerned, 
means, to desist from an application of the wire-extension 
method. The plaster of paris cast will therefore be the 
only means by which the affected limb can be kept at rest. 
An attempt should be made to obtain a careful primary 
reduction on the extension-table for plaster casts with 
a subsequent fixation by means of the combined fenestrated 
plaster cast with traction maintained by wires incorporated 
in the cast. An application of the extension method during 
rest in bed should be considered only under really station- 
ary conditions. 
3* Moans of transportation. 
The most conservative means of transportation is 
evacuation bv air. The primary condition for a good course 
of the evacuation is the permanent cooperation between the 
medical establishments of the Army and Airforce* Objections 
expressed in the beginning of the war against air evacuation 
in case of certain types of injuries (gunshot injuries of the 
lungs or of the brainX can be rejected as unfounded* During 
winter time especially good clothing or equipment for the 
protection against effects of cold have to bo kept available. The more improvised the ambulance vehicle is, the 
shorter must be the routes of transportation. 
Protective measures against the influence of the 
weather inside the vehicles (cold, sun, dust and rain) 
have been planned. During the cold weather periods the 
vehicles should be equipped, if at all possible, with 
thermos-bottles, hot bricks, stoves (instruction of the 
personnel about the danger of carbon monoxide) and blankets. 
In case of an evacuation on open vehicles (carts, sledges) 
sufficient straw and hay should be on the vehicles. During 
cold weather several wounded should be put closely together. 
4. Preparatory measures* 
a* General* 
Sufficient protective clothing against the influence 
of weather should be kept available, particularly for cold 
weather periods* Two woolen-head-protectors, 4 blankets 
should be available for each man, as well as two pairs of 
woolen gloves of which one pair should be gloves without 
fingers* Layers of paper should be put under the clothes, 
the extremities should be protected by stray;, rags and 
A sufficient number of aid-stations a "d rest-stations 
should bo established* 
b. Medical. 
1* Fixation. 
In case of uncertainty about the duration and route 
of transport, durable bandages which are able to with- 
stand the moving should be applied. 
2* Combating of pain. 
No morphine should be administered in case of gunshot 
injuries of the brain* No opium drugs, no S.E.S. and so on 
during cold weatherl In both cases Luminal will be useful. 
3* Support of the circulatory system. 
Due to the fact that in principle peripheral failures 
occur, drugs affecting the periphery are indicated, such as 
Sympathol, Veritol. 
5• Medical measures during evacuation* 
a. Repeated check-up examinations during evacua- 
tion, at least at all stations* The most frequent complica- 
tions during evacuation are; hemorrhages, collapse of the 
circulatory system, fat embolism, strangulation of the limbs 
caused by too tight bandages or by forgotten tourniquets. b. During the cold weather periods moist bandage-, 
should be renewed, no new bandages should be put over the 
old ones. 
c. The removal of lice infested plaster casts 
for the purpose of disinfestation should be up to the 
surgical wards exclusively. 
6• Technique of evacuation-dressings• 
a. The field transport splint does not serve 
the purpose of a permanent fixation but in general only as 
a means of fixation for the time of evacuation from the 
front lines to the place of the first surgical treatment. 
It must not be applied too tightly, the boots must not be 
removed and sufficient cotton must be put underneath the 
sole of the foot. The supporting belts should not be 
closed too tightly because of the danger of hyperemia- 
stasis* 
b. Plaster casts. 
Satisfactory fixation for evacuation is possible only 
with a plaster cast in case of surgically treated gunshot 
fractures and with a combined plaster cast with traction 
maintained by wire incorporated in the cast in case of gunshc 
fractures of the thigh. 
The plaster casts must be of sufficient size and must 
be well padded. 
In case of gunshot fractures of the upper thigh a 
plaster cast around the pelvis with a sort of plaster-pants 
to be applied to the sound side is necessary* 
In case of gunshot injuries of the joints the two 
joints next to the injury should always be included in the 
plaster cast. 
Unpadded plaster casts are prohibited as evacuation 
dressings. A good padding is the only guarantee of a 
sufficient supply of blood and at the same time serves 
as a protection against cold. 
c. Position of the limbs. 
The usual double right angle position of the upper 
limbs is not indicated for evacuation because of the large 
amount of space required. The most favorable position for 
evacuation is that with a slight abduction of about 40° 
in a triangular bandage with a frontally slightly elevated 
upper arm. A true abduction position should be avoided 
(IDESAULT bandage) as it cannot be foreseen how long the 
first bandage will remain* 40 
In case of gunshot fractures in the distal part of the 
thigh the abduction should remain limited to the width of the 
stretcher with consideration of the limited space during 
the evacuation. In case of gunshot fractures in the proximal 
part of the thigh fixation has to be made in an abduction 
position in spite of all difficulties concerning the evacua- 
tion! as an abduction position would under all circumstances 
necessitate an early later change of the plaster cast* 
d. Wound dressings. 
Moist dressings or dressings with ointment arc not 
indicated for evacuation, particularly not during a cold 
weather period. Also bandages with cod-liver oil ointment 
should not be applied because of their disagreeable odor 
in times of hot weather* 
/ 
Discussion; 
KILLIAN; KUENTSGHER himself has never recommended marrow 
nailing for gunshot fractures. VI. 
TYPHUS, WOLHYWIA FEY E.1 
RELAPSING FEVER. 
Translation prepared by: 
Office of Military Government for Germany (U. S* ) 
Office of Naval Advisor 
Medical Section A. Typhus. 
ly Variations in the clinical course. clinical prognosis. 
late damages. subsequent sequelae., Typhus-ence- 
phalitis , Well-Folia: rea ction, Otto-and V.cigl- 
vaccinos, duslffrom fecal'mattor of"lice*. 
Reko-sorum, time of administration* Therapy. 
Stabsarzt (Captain. MC.) Prof. 3PJ>ITQ.IAWN 
It is due to the particularities of our activities on 
the front lino that I can base this lecture on actual 
results of my observations much more than on theoretical 
knowledge. If one studies the corresponding sections of 
the literature one will find that not everything contained 
therein is in accordance with cur actual observations, in 
particular those theories which have been expressed in too 
short a catch-word style and too epigrammatically. 
To start with the catch-word concerning the relative 
uniformity of the clinical course of the disease it can be 
said that it does in no way conform to the variety of the 
various clinical pictures which can be observed during an 
epidemic of a larger extent. 
Thus we know of cases with a short period of incubation 
which as a rule lasted about 11 days as in the case of 
an Oberfeldarzt (Lt. Col., MC.) who became infected during 
his visit of hardly one hour in a PW camp in M* On the 
other hand we know of other cases with a prolonged period 
of incubation of more than 21 days, as was observed during 
an epidemic affecting the personnel of a field hospital 
at G., which spread from a particularly large and highly 
lice-infested transport of wounded. 
In addition there are cases where the diseases attacked 
a patient suddenly, as in case of a young physician, i ho, 
in the middle of a walk which he had started in perfect 
health was overcome by the fever to such an extent that 
he could hardly get back to his billot. 
Furthermore there are other cases with distinct pro- 
dromal symptoms as was the case with the chief-physician 
of a permanent P^'T camp which began with a miserable general 
feeling, weakness, inclination to giddiness and fainting, 
lack of appetite and insomnia* 
The disease starts as a rule with acute chilling, 
occasionally even with genuine shaking-chills. The body 
temperature raises quickly and with slight remissions and 
after 2-3 days reaches its peak and as a rule remains as 
high as 40°G. for 8-10 days. Most of these cases are 
combined with slight remissions, some single cases, however, 
may also show some pronounced intermissions. As a rule 
the fever declines within 1-2 days in critical cases; 
it is seldom that it declines lytically over several days. It is certain that no such pronounced bradycardia can 
be observed with typhus as in the case of typhus abdominalis, 
and as a rule, the pulse rate amounts in the beginning to 
100 to 110 but a still less distinctive distance from the 
temperature curve cannot be overlooked. Therefore, in con- 
trast to a theoretical opinion a certain relative bradycardia 
must be assumed, at least in the beginning* As a rule a glare 
at the temperature curve is sufficient for the expert to 
establish a preliminary diagnosis. 
There is quite a number of patients in whose case it is 
easy to establish a preliminary diagnosis after a mere glance 
at their so-called typhus appearance: brilliant red face, 
markedly inflamed conjunctivae. Generally one speaks of 
the so-called ’’rabbits eyes”. A comparison with a "bull” 
face is perhaps not very polite but in general expresses 
the meaning best. 
On about the third to fifth day of temperature the 
exanthema appears suddenly. According to my opinion, the 
slogan of an ’’explosive” onset of the exanthema which origins-' 
ed from LIPSCHUETZ is not the most fortunate choice* It 
would be easier to recognize the slogan of BRAUER about the 
development of the exanthema ”in one phase” which expresses 
a very short and clear cut differentiation between a gradual 
occurrence of the roseolae in case of abdominal typhoid; 
for it the typhus exanthem sometimes needs even more than 
24 hours for its complete development and spreading, in some 
single cases even days, it develops nevertheless in a con- 
tinuous sequence. 
One of its principal characteristics is its extensive 
variability of tender, pale-red maculae, which can easily 
be removed by pressure, which however, reappear quickly 
again and which develop into larger slightly elevated 
papulous spots which then can no longer be removed by 
pressure and which are not so bright red as typhoid roseolae, 
but which are of a dirty brown-red and frequently show small 
hemorrhagic centers. 
The exanthem is not equally distinct in all cases, 
frequently this is the case only after a certain lateral 
illumination particularly of the area of the flanks. Some 
authors recommend the use of flash-lights for the detection 
of the finest exanthem. 
Definitely there is also quite a number of cases taking 
their course without an exanthem. PLETNEW has observed 
up to 7 per cent of such cases of typhus without an 
exanthem during the well-known Moscow epidemic; other 
authors figure on 14, even up to 18 to 20 per cent. These 
figures appear somewhat high to me, however, as during large 
scale epidemics one will always have to take quite a number 
of abortive diseases into consideration, which are treated 
as outpatients, such cases of typhus sine exanthemata are 
only natural. In the environment surrounding typhus patients one rill 
always find quite a number of people who actually feel some- 
what uncomfortable but who, as hardened soldiers, did not 
pay any particular attention to that and yet in their case 
the Weil-Felix reaction shows a positive reaction of 1/400 
sometimes even 1/000, During the epidemic which had broken 
out among the personnel of a field hospital as mentioned 
before the commanding medical officer and his surgeon ob- 
served a certain feebleness in themselves, a lack of power 
to concentrate as well as a hitherto unknown clumsiness 
during office work and the chief medical officer noticed 
particular difficulties when writing, as well as a certain 
trembling in his hand writing* When they had made the 
Weil-Felix test on themselves later on, it turned out 
positive in both cases. 
Such cases of typhus exanthematicus ambulatorius are 
difficult to diagnose even for the expert. Their epidemio- 
logical importance, however, is not small, and this has boon 
pointed out only recently again by SEIFFERT in his attempt 
to establish an index about an epidemic spreading of typhus. 
i 
It should be pointed out by the way that such abortive 
cases .of typhus have been observed frequently since the 
introduction of protective immunization. It is not rare, 
that the typical exanthem is absent in those cases where 
protective immunization.has been made. The course is con- 
siderably shortened, the Weil-Felix reaction frequently is 
only slightly positive and even negative in some cases, so 
that occasionally one can get in considerable difficulties 
with the differential diagnosis of the corresponding case 
and its classification. 
As regardsthe Weil-Felix reaction it should be pointed 
out, that it is positive relatively late in case of an early 
diagnosis, but that according to the experiences made it 
increases distinctly as a rule. At the beginning non-spec:f'? 
agglutination on typhoid, paratyphoid and FLEZNkK dysentery 
can be observed. One should not be induced to establish 
false diagnoses as happens repeatedly. If the reaction 
Is made frequently enough so that curves can be worked cut 
therefrom, one will obtain ar increasing one for the Weil- 
Felix reaction and a decreaseng one for the non-specific 
agglutination. The crossing of one two curves is extremely 
characteristic for typhus but unfortunately it is generally 
not well enough known. 
There are, however, coses in which the Weil-Felix re- 
action remains negative during the actual disease in spite 
of frequent repetitions- and even this is not generally 
known - as we have observed in the case of a Captain of 
the Medical Corps whose reaction turned positive only during 
the reconvalescent period. 
The most remarkable symptom of typhus exanthem is its 
hemorrhagic respectively petechial change. According to our 
opinion it might be considered as, so to speak5 an external 
manifestation of equal sensory changes in tho central nervou 
system, therefore particularly in the brain. We are in the belief that as such they represent a very good indication 
for the severity of the anatomical changes in the brain, 
in short for the severity of the respective individual 
case, but that they also represent an indication of the 
effectivity of therapeutic measures. 
As is well known the excitants of typhus settle in 
the area of the capillaries and pre-capillaries. The 
endothelial cells swell with a simultaneously hyaline and 
necrotic change of the most internal layer of the wall. 
The capillary wall swells. However, only small sectors 
of the vessel will be affected. Fibrin exudates will then 
arise in the surrounding parts, combined with lymphocytic 
and plasmacell infiltrations and by gradually increasing 
adventitial and peradventitial exuberant growth of cells 
to a ball-shaped or spindle shaped attached swelling, the 
so-called little typhus knots. In the brain and in the 
spinal fluid these are located exactly in the grey sub- 
stance. In addition there is prolific hyperplasia of the 
neuroglia, edema of the brain and the meninges and finally 
hemorrhages. Most affected are the stem of the brain, 
floor of the fourth ventricle, pons and medulla oblongata. 
According to NICOL it appears justified to compare 
typhus with periarteriitis nodosa and for this reason he 
correctly considers the disease of, the smallest vessels 
characteristic for typhoid as arteriolitis respectively 
periarteriolitis nodosa. 
On the other hand a similarity with epidemic enccphalitir 
is marked and therefore one should not be surprised if one 
finds neurological changes which remind one of the picture 
of the ECONOMOS-encephalitis lethargica. The typical loca- 
tion of the small typhus knots permits the establishment 
of characteristic neurological syndromes as were well ce- 
monstrated by Prof, von STOCKERT. The extent of the anatomic- 
al processes easily explains the severity of the psychic 
changes which may even develop into a catatonic clinicrl 
picture as was described by MUNK, By thrombotic processes 
and hemorrhages, hemiphlegia may occasionally arise, which 
in particularly serious cases can be irreversible to a 
certain degree in contrast to the other changes caused by 
typhus encephalitis. 
The opticus, facialis and particularly the acousticus 
nerve are affected among the cranial nerves. Giddiness, 
difficulties in hearing and tinnitus can last a long time, 
even during reconvalescence. 
The peripheral nervous system is also affected, par- 
ticularly in the area of the lower extremities and to a 
larger extent than in case of polyneuritis, while paralyses 
of the nerves occur more easily in the area of the upper 
extremities, particularly in the area of the ulnaris. 
The fact that the small typhus knots are most frequently 
located in the area of the floor of the fourth ventricle 
explains the various vegetative disturbancesj but in par- 
ticular it also explains the sequelae following an injury of the vasomotoric center* In this connection tho character- 
istic decrease of the systolic blood pressure and the diminu- 
tion of the amplitude of the blood pressure resulting there- 
from must be mentioned first of all* 
It is probable that the marked decrease of weight of 
the typhus patients can be explained by anatomical changes 
in the area of the vegetative centers even if the clinical 
picture does not appear to be too serious in the beginning. 
The sequelae can be explained particularly hy the 
centrally influenced changes of the vessels, as they can 
be observed in serious cases in the form of a tendency 
to decubitus, gangrene of the fingers and toes, ever the 
hands and feet and to extensive necroses of cartilaginous 
parts as of the ears, nose and larynx. 
Additional dreaded complications are phlegmons, furun- 
culosis, parotitis, otitis media and especially more or less 
extensive pneumoniae, which are sometimes generalized, but 
more often localized and occasionally even suppurative due 
to a superinfection with streptococci, in some single cases 
even gangrene of the lungs* 
A diseased heart is an additional important factor 
which must not be overlooked. Especially from there the 
spreading of small typhus knots starts and results in 
a disseminated interstitial myocarditis of the right as well 
as of the left heart, particularly below the endocardium. 
If the conduction system is affected, various functional 
disturbances result therefrom* Even in case of a progressive 
reconvalescence there are - as we have seen in the case of 
two young physicians - occasionally quite unexpected more 
subita with a secondary arrest of the heart action* 
BREDNOW has observed distinct disturbances of the heart 
and circulation even 1-2 years after the patient had 
recovered from typhus. 
A short while ago WALTHER described secondary diseases 
subsequent to typhus which were marked by renewed, increases 
of temperature after the temperature had already returned 
to normal combined with a renewed swelling of the spleen, 
occasional urticaria, slight neuritic symptoms, and in one 
case painful effusion into a joint* Ho mentioned that 
SCHITTENHELM too had observed such short lasting "secondary 
fever". We saw similar cases ourselves but we believed that 
the slight increases of temperature were damages duo to a 
too early transport of the patient. I am convinced that 
in the case of typhus there are recrudesces similar as with 
abdominal typhoid, but on the other hand I could observe a 
genuine relapse with renewed exanthemata after a period 
of about 14 days without fever. As far as the prognosis 
of the single cases is concerned we have to s?.y that it 
depends on the age of the patient, which can easily be under- 
stood because of the pronounced changes of the vessels in 
case of typhus. On the average one expects a 50 per cent 
mortality rate in case of patents over 40 years of age. 
This about corresponds with our own observations* This high mortality rate is considerably reduced by the 
protective immunizations which are now given to more people. 
This immunization does not eliminate the contracting of 
the disease, but it protects according to our experiences - 
and this seems to be of special importance to me - older 
people against an otherwise threatening tragic course. 
We have at our disposal practically only experiences 
made with the WEIGL vaccine. 
That it is possible to improve the prognosis with older 
people sometimes by therapeutic measures v-ill be discussed 
in detail later on when I shall talk about the treatment. 
According to experiences the kidneys as a rule are more 
or less affected in case of typhus. A prognosis with those 
patients who a short time before had suffered from a tynical 
field nephritis cannot be made very clear* 
The same holds true in case of all patients who had 
previously suffered other severe infections like scarlet 
fever or diphtheria, as is not rare according to our ex- 
periences. 
It is natural that the general state of vitality has 
to be considered when making a prognosis.. 
As a result of all these above mentioned complications 
and sequelae after typhus, the prognosis will become worse. 
Generally it can be said that typhus will take a more 
severe course with people who like ours have not been in- 
fected and immunized to a certain degree becau.se they did 
not have repeated typhus epidemics through past generations. 
This point of view was already proven during World War I 
and is now substantiated again by the experiences of this 
war* 
As regards the aforementioned, one must not overlook 
that all epidemics have distinct peaks of morbidity and 
mortality, the same holds true for typhus. Russian physicians 
told me that they observed peaks of morbidity between 
November/December, December January and finally February 
and March, and furthermore an increased mortality toward 
the end of March. 
In this connection the observation of the Russian 
physicians may be of interest, who observed that the power 
of resistance of their captured comrades had been reduced con- 
siderably by the marked loss of strength. While in former 
times they considered a period of immunity of 20 years after 
typhus, they state, that according to their present ex- 
periences immunity lasts about 5 years only. They frequently 
observed relapses of typhus. One Russian prisoner who 'was 
captured during the war had typhus three times and the last 
time with a fatal ending. Concerning the therapy of typhus we have to state that 
we are still in a testing phase. However, it is my belief, 
that the latest observations give us certain hope that 
we are at least on- the right way. With the at first 
enthusiastically accepted method of giving transfusions 
with the blood of rcconvalescents we could insure 
a certain recovery for the respective patient. Wo cer- 
tainly could not have expected more, as the experience 
with the serum of convalescents laid down in literature 
did, according to my knowledge, not promise much success. 
The intramuscular injections of the patientfs own blood, 
as has been proposed by Polish physicians rero not even 
tried at our clinic. As I have observed, Eubasin has 
found various reviews in the literature. In my opinion, 
however, it has the advantage of eliminating the other- 
wise dreaded complications of the lungs to a certain 
extent. 
Also the treatment with Atebrine and Plasmochin 
inaugurated by Second Lieut. Medical Corps MEERENDONK 
did not fulfil all the expectations of ,the author. He 
is now expecting better results in case of a simultaneous 
administraten of calcium and his point of view is based 
on the idea of having Atebrine produce a specific effect 
on the richettsia circulating in the blood and to have 
calcium produce an effect which tightens the walls of 
the vessels and has a generally inhibiting effect on 
inflammation. As a matter of fact he was in earlier 
days of that disease able to prove a reduction of the 
blood calcium level to 6 and later on to 8 mg per cent. 
Tetanic symptoms in case of typhus have been known for 
a long time. Dr. VAN MEERENDONK is now using the follow- 
ing procedure: 3 times per day 0.1 gram Atebrine per os, 
in addition 10 - 20 cubic centimeters calcium gluconicum 
20 per cent which quantity may in serious cases be in- 
creased to 40 cubic centimeters. If calcium gluconicum 
is not available at the moment, the corresponding quantity 
of 10 per cent calcium chloratum can be administered. No 
fatal cases were observed by VAN MEERENDONK among 60 
patients treated that way, some of which were even cf 
advanced age and this fact seems to be particularly im- 
portant to me. The exanthem was less extensive#according to 
his observations and also became less hemorrhagic and 
petechial, a fact which appears to be of particular signif- 
icance to me. In addition no more cases of decubitus 
and very few cases with complications of the lungs oc- 
curred, The blood pressure did not decrease so markedly 
since that time, at any rate it never decreased below 
100 mm. Hg. 
Quite similar to this a considerable reduction of 
the blood calcium level was observed at the clinic cf 
Prof. VEIL at Jena. At this clinic a treatment of the typhus 
patients with T-C-6 (Calciumthiosulphat MScheringM) 10 
cubic centimeters was started as the most important anti- 
allergic remedy; in particular, however, A-T-10 was used for 
the treatment which is also an anti-allergic remedy similar 
to vitamin, stimulating the calcium level. The daily close amounted to 1 teaspoonful, in serious cases as much as 
1 tablespoonful with a simultaneous intramuscular ad- 
ministration of .Cortiron. This is a therapy therefore, 
which is based on comparable observations and appropriate 
conclusions and intentions. Also in this case the course 
of the disease was considerably milder and the duration 
was shortened, the exanthem has been less extensive and 
less hemorrhagic and the central nervous symptoms were 
less dramatic. If one does not consider the case of a 
72 years old swim-master, the VEIL clinic had only one 
fatal case among 25 patients which corresponds to a 
mortality rate of 4 per cent. 
If the small number of patients on which the observa- 
tions of VAN MEERENDONK and VEIL are based are not mis- 
leading, the treatment with high doses of calcium appears 
to be promising and commendable. The question whether 
or not Atebrine should be administered simultaneously 
can only be decided by further observations in the sense 
of a comparable therapy. 
Similar facts also apply to the administration of 
Frostigmin, as recommended by Prof, von STOCKEHT. Due 
to the lack of a sufficient amount of clinical material, 
however, I am not yet in a position to form a final 
opinion on the subject. Prof, von STOCKEHT expects 
Prostigmin to have a central tonic effect on the entire 
muscular system as well as on the cardiac muscles and he 
therefore assumes that it also counteracts any threatening 
weakness of the cardiac circulation. 
In spite of everything said above one should according 
to my opinion be much more concerned with keeping the 
patient at rest in the sense of the sedative treatment 
according to HAUSMANN, than is generally the case. 
Physicians who have suffered from this disease have re- 
ported to me how sensitive they have been against effects 
of light and noises. 
One of them could hardly come to an end with his_ 
praising comments on the convenient effect morphine 
injection, after all previous remedies had failed to 
produce a favorable effect* 
In contrast to the statements of HAUShANN I do not 
wish to desist from an early administration of remedies 
supporting the cardiac circulatory system, especially of 
Strophantin. In every other respect, however, we should 
similar to the methods applied by the Russians hold back 
with every officiousness (polypragmasy) no matter how 
good the intentions in this respect are and the nursing 
personnel should be trained for a most careful observation 
of the patients, while our younger colleagues must be in- 
formed in an expert observation of the pulse and an early 
prevention of the threatening collaps of the circulatory 
system. 50 
-2» Variations in the clinical course, clinical prognosis, 
late damages % subsequent sequelae, Typhus-ence- 
phalitis, reaclTIon, Otto and Weigl- 
vaccines, dust from fecal matter of liceT 
Heko-serum, time of administration. Therapy. 
Oberarzt (1st Lieut., MC.) Dozent SCHULZE 
A considerable portion (about 30 percent) of all 
typhus patients who have received treatment in the area 
under my control, among them physicians, stated that they 
have never had lice. Even if we take if for grantee that 
only a small portion of these patients have convinced 
themselves by a daily examination of their clothing that 
they were free of parasites, the fact will, remain that 
typhus occurs also without a contamination of lice bites 
with infected fecal matter of lice. 
In a typhus hospital for Russian PWfs physicians 
and medical personnel had to wear tight protective clothing 
and rubber gloves. In spite of this protective measure, 
however, the majority were infected with the exception of 
those who used to wear captured Russian gas-masks when 
entering the highly infected rooms. 
Only in very rare cases does the infectious material 
penetrate through small superficial wounds; more frequently 
the infection is caused by a contact with the mucous 
membranes, in which case the conjunctiva appear to be par- 
ticularly exposed to danger because of the possibility 
of embrocation. 
The frequent conjunctivitis among physicians and 
personnel in the typhus institutes of Lemberg and Cracow 
appears to be explainable by this fact. 
Furthermore numerous individual observations and 
experiences gathered from typhus institutes emphasize this 
mode of infection. 
In this connection one must also consider the 
possibility of an infection by droplets discharged by cough- 
ing typhus patients. This point of view appears more justi- 
fied if one thinks of the frequent complications of the 
lungs as a specific disease, which might be proven by the 
resistance toward Eubasin treatment. Even though PLETTNEW 
has made the observation that an orthodox pope did not fall 
ill in spite of his kissing of dying people, this does 
by no means affect this conception. 
For diagnostic purposes the Weil-Felix reaction has 
proved just as useful in case of a correct evaluation as 
the rickettsia agglutination mentioned by WEIC-L. It must 
be noted in this connection that there is no relationship 
between the level of the titer and the seriousness of the 
disease or the content of protective bodies in the serum. Apart from a larger specificity the difference con- 
sists first of all in the fact that the rlokettsia 
agglutination according to WEIGL does on occasion not 
only rise at an earlier time and reaches higher values 
during the course of the disease and seldom decreases, 
but it remains also for a prolonged period of time* 
The rapid reaction according to the method of 
KALLMANN is in general parallel to the Weil-Felix reaction. 
The agglutination with Proteus x 19 will seldom 
turn out positive before the 5th or 6th day, in exceptional 
cases even only at the end of the 2nd week* Ordinarily 
the reaction grows increasingly stronger and then decreases 
again after a couple of weeks* 
If the statements made above represent the rule, 
exceptions will occur on occasion which should not be 
overlooked and ought to be mentioned as well* 
1* Some single clinically clear cases of typhus 
did not show an agglutination according to Weil-Felix 
in spite of several repetitions of the test* 
2* Agglutination of Proteus x 19 has been observed 
in case of injuries due to cold, diarrhea, angina and 
icterus (also with an increasing titer), without clinical 
symptoms of typhus being noticeable* 
3* Patients who definitely suffered from typhus did 
not show an increase of the titer level in the course of 
the disease and cases where the level remained, constant 
were just as well observed as cases where it decreased. 
As regards the level of the titer itself? it should 
be pointed out that with equal clinical material differences 
were observed in the various test laboratories (Is200, 
1:400, 1:1200 or 1:1000 and 1:400) which will be unavoid- 
able until one succeeds in producing constant agglutihable 
Proteus x 19 strains. 
An analogous relationship exists between people 
vaccinated with the serum mentioned by WEIGL and the 
Weil-Felix reaction. 
If it is in general impossible to establish diagnoses 
based exclusively on the result of one single'reaction 
this realization will gain even more importance in this 
case* 
Due to the insufficient acquaintance of many physicians 
with this clinical picture a final diagnosis "typhus'* after a 
single result of 1:100 or 1:200 is an impractibility, leads 
to confusion and aggravates the evaluation of clinical and 
therapeutic results in addition to the diagnosis* There will hardly be any other disease except typhus 
where the value of a good prophylaxis for the treatment 
becomes so evident: 
Out of 250 patients treated with the WEIGL vaccina- 
tion serum 4 died - le6 per centc 
Out of 1250 patients without previous treatment with 
the WEIGL vaccination serum 240 died - 
19*2 per cent. 
In this connection it must be pointed out that only 
one patient ouc of the four who died had received his vacci- 
nation in due time9 while in the case of the remaining three 
patiantc the immunization had only been started. 
A protective immunization in cue time offers an al- 
most absolute protection against a fatal issue in case of 
an Infection. Even a vaccination curing the period of in- 
cubation does not have an. unfavorable effect on the further 
clinical course of the disease. At tie time when the dis- 
ease has reached its xiala, however5 o continuation of the 
vaccination appears to me t r be net’quite harmless. One 
patient whose case became Ancon to me died 48 hours after 
such a procedure. In every other respect it can be said 
that the clinical course of those patients who had re- 
ceived one or two vaccinations was a much milder one than 
of those who were not vaccinated'at all. 
The clinical course of the disease was a much milder 
one with patients who had been vaccinated previously. In 
particular I wish to point out that the serious disturban- 
ces of the central nervous system hardly ever occurred, 
the circulatory system ¥;as less exposed to danger, the exan- 
thema was frequently of a short duration only and the fe- 
brile period was frequently shorter and the temperatures 
as such were lower. Naturally, the remaining usual thera- 
peutic measures must not be neglected. 
Unless methodical or financial factors are of signi- 
ficance, there is no reason why one should change and use 
OTTO-vaccination-serum. I do not have the necessary ex- 
perience based on a sufficient number of cases observed 
to form an opinion on this serum. 
I wish to report about our observations on almost 
2000 typhus patients without discussing the practical 
experiences and those based on animal experiments con- 
cerning the treatment of typhus vwicli are contained in 
the literature. 
During the treatment of typhus, patients, the support- 
ive therapy of the circulatory system is most important 
besides the usual external treatment and the special diet 
along with which a sufficient amount of liquid must be 
administered. 
As regards the administration of Strophantin. Camphor 
and remedies effecting the central nervous system it must 53 
be pointed out that one should not wait until the blood 
pressure decreases or the pulse rate increases* 
As the recovery from fever will take a considerable 
length of time, particularly with the serious cases, and 
as this involves certain hazards for the circulatory sys- 
tem, cardiac remedies should be administered also during 
this period. 
Since there are all kinds of transitional changes 
in case of typhus, beginning with death caused by acute 
myocarditis to vagus cardiac inhibition which frequent- 
ly are of such degree that an intensive supportive treat- 
ment of the circulatory system can be life-saving, one 
must not desist from the administration of remedies sup- 
porting the cardiac and circulatory system, and also not 
from those affecting the central nervous system* 
With conditions of excitem-.nt and motor unrest 
Scopolamin-Eucodal-Eohotonin Ts~*E*E.) has proven useful 
everywhere* An attempt should be made, however, to get 
along v-ith more harmless remedies first* 
Sulfonamides (be 1034, Eubasin, Prontosil, Cibazol) 
have not shown a specific effect oven wlm in 
large doses* Even in case of typhus pneumonia, which 
can be observed frequently, Eubasin had no 
effect* As mentioned in the beginning typhus pneumonia 
is possibly a specific disease of the lungs, a fact which 
might explain this failure* 
The attempt to obtain an improvement by small doses 
of Pyramidon (five times 0*1 grams per day) did not meet 
the expectations• No reduction of the temperature could 
be observed, the general condition of the patient re- 
mained unchanged* 
Nova1gin was administered with 25 patients suffer- 
ing from typhus in doses of 5 cc* intramuscularly once 
or twice per day* In every case a critical decrease of 
the temperature accompanied by profound perspiration 
occurred* No improvement of the excitement could be 
achieved as well as no improvement of the^intake of food 
could be observed* Almost all of the patients felt worse 
after the decrease of temperature, suffered from a severe 
feeling of illness and rejected any food. Occasionally 
an aggravation of the pulse rate was observed. About 
8-12 hours after the administration of this remedy the 
temperature rose to the previous height and the further 
clinical course could under no circumstances be con- 
sidered as improved. 
Mercury preparations (Salyrgan)are useless and with- 
out influence on the clinical course of the disease* 
The. administration of Vitamin K and P did in no 
case show a convincing effect, but it must be pointed 
out that the number of cases observed is small* An 
essential improvement or innovation can hardly be ex- 
pected from this remedy* Lumbar punctures are of no diagnostic or therapeu- 
tic value* 
The hospital reports available are not sufficient 
for a definite evaluation of a grape sugar therapy 
(40 cc. of a 25 per cent solution injected intravenous- 
ly). 
Furthermore the question of treatment with calcium 
will remain open* Russian physicians' like to use this 
treatment because of its vaso-constricting effect. 
The results of the treatment with serum of convales- 
cents and the value of this therapy is not quipe clear as 
no alternate 5 comparable therapy was applied every .jeers,* 
In any case the results are not convincing. 
In Cholm, blood was taken from convalescent patients 
on the 8th to the 10th day after defervescence. This blood 
was defibrinated by whipping and was left alone over night. 
The serum was obtained after sedimentation and v/as injected 
intramuscularly (30-50 cc.) without any. further addition. 
18 patients were treated this way, out of 'which 11 
died, with 4 no influence on the further clinical course 
of the disease could be observed while an improvement of 
the general condition could be noticed with 3 patients. 
The evaluations made in the reserve hospital at 
Cracow are not based on objective findings, but one "has 
the impression that the injection of the serum has a favor- 
able effect particularly as later on it wps administered 
in doses of 40-50 cc* 2 to 3 times* The feeling of giddi- 
ness of the patients disappeared, headaches vanished entire- 
ly* 
The small number of patients treated with convales- 
cent serum at Lemberg also does not permit one to form a 
final opinion although at this place alternating methods 
were applied without selecting the patients* Out of 18 
patients who had not received convalescent serum 3 died 
while of 8 patients treated with convalescent serum 1 died* 
Although our observations do not permit us to draw 
final conclusions, they will in any case justify a further 
use of convalescent serum. More * Impressive results can surely 
be obtained if it is used earlier* 
Supplementary to what has been said on page 72 con- 
cerning the collection of medical experiences in the 
it can be stated that the withdrawal of blood from con- 
valescent patients may take place 8-12 days after the de-4- 
crease of the temperature. "hen this procedure was used .in 
the hospitals of Cholm, Cracow and Lemberg, no harmful 
effects were ever observed. 
!f we survey our therapeutic experiences we can 
consider it as a positive result that the majority of 
drugs mentioned did not fulfill our requirements and that 
we are still far from a specific therapy* Msinfestation. lice-powder-. Infection by, fecal 
matter of lice* Is disinfection necoasary 
in addition io disinfestaFion? 
Qberstabsarzt (Major. MC*) Dozent EYEH* 
The methods of disinfestation in areas contaminated 
or endangered by typhus have to be directed in such a 
manner that the transmitters of typhus, the body louse, 
as well as the excitant of tyohus, the rickettsia pro- 
wazeki can be destroyed with certainty* Every method 
which shows gaps in this regard, has to be rejected, 
as it indicates security where there is none* This holds 
true for the majority of all chemical means of delous- 
ing, especially gas- respectively vaporiform means of 
delousing which can be obtained in the free tr?de. The 
fact, that an efficient means of delousing is not also 
a disinfectant is overlooked quite frequently* 
Typhus, contracted by body-lice, is an intestinal 
disease during the course of which a large number of 
infectious rickettsia are excreted, which, enveloped in 
small particles of fecal matter have a great resistance 
against gas or vaporiform agents* The ability of the 
fecal matter of lice ot disintegrate easily, aggravates 
the danger originating therefrom to a large extent. As 
it cannot be doubted, that the epidemic spreading of 
typhus depends principally on the existence of live-lice, 
it can be proven on the other hand, that the origin of 
some, at first single cases of typhus can be traced back 
to infection by dusty fecal matter of lice* The old Po- 
lish epidemiologists tell quite a story about the im- 
portance of the epidemiology of typhus as regards the 
trade with clothes which in the eastern areas had for- 
merly been exclusively in the hands of Jews* 
According to our experiences up to now the old 
procedure of a sensible use of dry heat has shown the 
best results, in as far as one takes care that the de- 
lousing establishments do not have more work to do as 
they can actually perform. It is essential, that the 
heat produced will affect the items which are to be de- 
loused every-where and that it is available in the right 
temperature quickly and for a sufficiently long period 
of time. The mistake made most frequently is that the 
delousing-chambers are packed too tightly with clothes 
and thus the delousing procedure becomes ineffective* 
An additional mistake, which is based more on the con- 
struction of the establishment than on the management, 
is the unequal distribution of the available heat. She 
temperature is limited: the lowest temperature which 
will kill lice, nits and rickettsias in the 
time has to be considered, the upper limit of the tem- 
perature depends on how much heat the items to be de- 
loused can stand. The simple rule: 90°C for 90 minutes 
is justified, if the items to be deloused can stand it* 
The heat-technicians, who have mainly to be concerned 
with these matters, should have gained enough experi- 
ence during the past 2% years of war to be able to 
solve this problem. Articles which will not stand a disinfestation 
with hot air must he disinfested-with chemical agents* 
Among these chemical agents, Cresol, which has been 
made soluble in water by some emulgent was the only 
one proving useful in the long run* The use of lotions 
containing Cresol for the delousing of the human bodies 
is commended* 
The disinfestation of rooms from lice in typhus 
areas is difficult or practically impossible in these 
days* A skillfully applied disinfection by scrubbing 
with Cresol-preparations is always indicated for those 
places where it is possible* 
Another problem which has not yet been solved is 
that of the delousing of wounded, particularly of those 
with plaster casts* Also in this case the treatment 
with hot air appears to promise success, as it can be 
produced for instance in Pn appropriate hot air box of 
the necessary dimensions* The previous insertion of 
a sprayed stimulant for human parasites (Pyrethrin) is 
recommended* 
The disinfection of the patient suffering from 
typhus following the disinfestation of his equipment 
must if at all possible be performed prior to the hos- 
pitalization in the special ward for infectious dis- 
eases* A regular disinfection after certain inter- 
vals of time will not be necessary, but a disinfec- 
tion at the end of the treatment should be considered. 
Considering the high sensitivity of typhus agents 
againi liquid chemicals the problem, which kind of dis- 
infectants should be applied, is of no importance, on 
the other hand, the availability of raw materials plays 
an important 
As regards preventive measures against infestation 
with lice, I only made experiments with Cresol and Phenol 
preparations* First of all a suitable method of appli- 
cation was sought. Ointments and powder were taken in- 
to consideration which could create an atmosphere of the 
respective disinfectant on the surface of the skin. The 
question, how long this atmosphere will remain is the 
principal problem. By experiments performed on myself 
I made the experience, that neither powder nor ojitments 
are satisfactory. It was found that after the appli- 
cation of Cresol ointment or Cresol powder the charac- 
terisitic odor of Cresol could not be observed after 
7 hours had passed since the entire amount of Cresol 
applied on the skin was dissolved in the skin and had 
penetrated into the organism. If these drugs were 
regularly administered to the skin one soon was faced 
with symptbms of a genuine poisoning. 
Cresol powder was manufactured during World War I. 
but it was not accepted for general u£e. Samples, sent 
to the field units lately had no success with soldiers 
strongly infested with lice. There are reports that a new preparation composed of powdered tobacco and 
Cresol derivatives was successful in a PW camp where 
Russians were detained. I do not think that this 
messy substance will become popular. It was not 
possible to gather a personal experience with phtal- 
ic acid preparations. 
4jg The Exanthematic typhus occurring in this War 
as compared to that observed from 1914 to 1918* 
Gberstabsarzt (Major. MG*) Prof* GRUBER; 
The following statements are based on the results 
of 65 post mortem examinations vithin the district of 
the Xlth corps and on the examination of cardiac walls 
of 17 other patients who died in the clinic of Oberarzt 
(1st Lieut*MC*) Prof. Dr. Werner SCHMIDT. Furthermore 
notes written by Prof# Dr. Werner SCHMIDT and Oberarzt 
(1st Lieut.MC.) Dr. KOEBERLE were used. 
As a principle it must be stated that no essential 
difference can be observed between the manifestation of 
exanthematic typhus during World War I and this war* If 
one regards the reports of CEELEN, JARISCH, Georg HERZOG, 
DAWYDOWSKIE and NICOL, one will find even the minor de- 
tails of what we observed with the post mortem examin- 
ations during this winter. The material available to us 
was much more extensive and in addition a considerably 
larger number of medical officers was concerned with 
that matter, some of whom studied this disease for the 
first time* It is only natural that observations were 
made which were liable to surprise an observer who for 
comparison used only the classical picture of the find- 
ings of the exanthematic typhus which became familiar 
to us during World War I. 
The classical sign of the exanthematic typhus in 
the tissues is and will always be the so-called exan- 
thematic typhus nodule which is a more or less well 
defined nodule consisting principally of inflammatory 
products and a focal accumulation of cells attached to 
the small blood vessels, particularly to those of the 
central nervous system and the skin. These discontin- 
uous cefcl foci, which do not always appear as nodules 
but sometimes may be rather stretched out, sheathing 
the vessels like sleeves, usually enclose altered parts 
of the endothelium, thrombotic contents of blood vessels, 
increased perithelial cellular elements and infiltrated 
migrating cells* Recently, however, HEECK made the 
correct reference that nodules with merely adventitial 
cell proliferations occur in addition to quite insig- 
nificant exudations and with almost no injuries of the 
vascular walls* Here, the formation of small granu- 
latoma occurs* I agree with HUECK, if he is opposed 
in this sense to the frequently used comparison with 
the picture exhibited by the vascular tissues in cases 
of periarteritis nodosa* Even if findings similar to those of periarteritis nodosa are occasionally seen 
they can by 10 means be considered as a rule* I 
have not yec been able to make such an observation- 
myself. Moreover various organs are not equally af- 
fected by the occurrence of such nodules during ex- 
anthema tic typhus, first of all the distribution 
varies with the organs. In the central nervous sys- 
tem, particularly in the grey parts of the meduiTh 
oblongata and of the brain stem one succeeds best in 
searching for these characteristic nodules. The search 
for nodules in the cardiac muscle is less successful. 
Secondly, the gliogenous structure of the supporting 
tissue of the central nervous system makes a parti- 
cipation of the gliogenous cell production possible 
in the formation of nodules. This, of course, is 
entirely absent in the skin, the heart, etc. Thus, 
the usually more compact struct in e of the cerebral 
and spinal nodules may be- explained. On the other 
hand loose lymphocytoid infiltrations are frequent- 
ly seen in the skin along large precapillary and 
capillary, arterial and venous stretches of the sub- 
papillary vascular network, in addition to the typi- 
cal nodules. These too, are coat-like accumulations 
of cells, within which one is not always able to 
prove swollen or congested parts of the endothelium. 
Thus, the examination of the skin of patients who 
died from exanthematic typhus, infrequently shows 
the typical nodules of FRAENKEL,-not even in serial 
sections - but rather diffuse, non-characteristic 
lymphocytoid infiltrations around the smallest 
vessels of the superficial layers of the corium. 
As to this the suggestion to make sure the diagnos- 
is of the exanthematic typhus by histological ex- 
amination ofexcised parts of the skin seems to me 
not so successful in practical cases as was origi- 
nally promised by the observations of EUGEN FRAENkEL. 
some time ago. However, conditions nay be favor- 
able with early excised exanthematic parts of the 
skin of patients while alive. If conditions are 
very favorable one m-y be able to diagnose the 
exanthematic typhus from excised parts of the skin, 
this, however, is not always certain. 
The fact that on the basis of their experience 
the clinical physicians did not consider the in- 
volvement of tho heart in exanthematic typhus as being 
of particular importance during World War I gave rise 
to the examination hlsto-pathologically of various 
cardiac alterations. In recent times these efforts 
could be further extended. They confirmed the oc- 
currence of exanthematic typhus nodules in the vas- 
cular system of the heart. These nodules, however, 
are often very loose and frequently one tried in 
vain to find them, while an often only very slight 
and focus-like distributed interstitial myocarditis 
between intact muscular areas was found by me in 
every cardiac muscle of the exanthematic typhus patients which was examined. In these cases these are 
no leukocyte infiltrations but stretched lymphocytoid 
and plasma-cellular infiltrations which are attached 
to the capillaries between the muscular fibers and which 
of course may be spindle-shaped accumulations when the 
interstitium is wide. From these various stages of 
transition loose vaguely delimited forms of nodules 
originate. Repeatedly more delimited infiltrations 
similar to nodules were found in the borderline area 
of the muscular system and the subendocardial or sub- 
pericardial supporting tissue, such as the terminal 
area of the papillary muscles. Occasionally this prin- 
cipally spotty interstitial myocarditis is exessively 
pronounced. In contrast to this one usually searches 
in vain for more pronounced symptoms of degeneration 
of the cardiac muscle itself. Usually there is no waxy 
swelling, no clodded decay, and no infiltration by fatty 
droplets. This does not exclude that spots of fatty 
muscular degeneration occur, or the rarely observed de- 
limited decay of muscles with an enormous lymphocytoid 
infiltration surrounding it subsequent to an inflamma- 
tory thrombotic occlusion of a very small branch of the 
coronary artery. 
It is a remarkable fact that this interstitial 
myocarditis can be traced by the clinical electrocardio- 
graph. If, however, many findings are compared one sees 
that the curves are made rather carel.essly and are not 
put in a system and moreover, that the pathological pic- 
tures are quite reversible. This experience was reported 
by the consulting medical specialist of my Army District, 
Oberstabsarzt (Major, MC.) Professor Dr. SCEOSN. Never- 
theless a transitory cardiac involvement in the whole 
picture of the severe circulatory disorders of the pa- 
tients suffering from exanthematic typhus must not be 
underestimated, even if one has to admit that the early 
typical drop of the blood pressure of these patients 
might be of a central origin, or that it was even found 
with patients whose cardiac muscles revealed only very 
slight myocarditic alterations during the post mortem ex- 
amination. A cardiac involvement has always to be re- 
garded as serious, since in the course of the exanthe- 
matio typhus a sudden and unexpected death sometimes 
occurs, which according to HERZOG suggests a death due 
to a diphtheritic heart failure, or which may happen 
with the clinical picture of the coronary occlusion. 
Werner MEYER gave me a report of his personal experience 
of a most disturbing stenocardiac attac occurring during 
the first period of recovery and not showing the typical 
electrocardiographic picture of myocardial infarction. 
But these cases are also singular. The previous ex- 
perience and the electrocardiograms show that the myo- 
carditis disappears and is cured. The experience made 
with the hearts of people having suffered from typhus 
shortly before or previously shows whether soars of the 
structure of the myocardiac syncytiums develop, which I 
would not consider as probable. 
Endocarditis was not frequently observed as a sign 
of the petechial fever. They hardly occur primarily with 
the valves. But it has been found that an auricular, ven- 60 
tricular endocarditis and an endocarditis of the 
chords must be taken into account-a continuation 
of a myocardial Inflammatory Infiltration which may 
lead to a throrabo-endocarditis. More or less extended 
sequelae of embolism of the lungs, formation of embel-** 
ic foci in the brain, and even sudden death due to cere- 
bral embolism are as possible as necroses in the area 
of the extremities from the same causes. In addition 
one must bear in mind that peripheral thromboses ,gauoed 
by a periarteritis or by a periphlebitic alteration of 
large vessis may occur with all their serious conse- 
quences for the organs concerned. The occasional oc- 
currence of bronchial, gastro-intestlnal, renal and 
muscular hemorrhages is thus explained. Furthermore, 
I want to mention that I found no large petechial pur- 
puralike hemorrhages with the material available to me 
for post mortem examination. 
Moreover, it should not be omitted that the kid- 
neys too are usually Involved showing a interstitial fo- 
cal inflammation, even if there are no obvious clinical 
symptoms. The small foci are linked to capillary and 
pre-capillary blood vessels, sometimes even to the inter- 
lobular ramifications of the arcuate vessels. They may 
occur as characteristic nodules with a swelling of their 
endothelium, usually, however, it can be shown that they 
are paravascular, lymphocytoid accumulations not affect- 
ing the vascular lumen. The same small foci are alsa 
found in the cortical area. A focal glomerulp-nephritis 
was never observed by me, though it alledgedly occurrs. 
The experimental pathology of the exanthematic 
typhus showed how important the enormous toxicity of the 
causative virus is. The sometimes occurring extensive 
alterations of the liver may probably be caused by this 
property of the virus. Werner SCHMIDT reports that dur- 
ing an exanthematic typhus he observed very often the oc- 
currence of an icterus. In the old literature reports 
are given of a degeneration of the liver with a cell des- 
quamation in the capillary area of the portal vein* In 
one of our cases we found not so much a degenerative im- 
pairment of the liver as a hepatitis with an intracapil- 
lary increase of migrating cells and macrophages similar 
to what is occasionally seen during scarlet fever. No 
large autopsy experience is published yet on this matter. 
At last it 3s generally stressed that in addition 
to the typical vascular nodules due to typhus the oc- 
currence of laose, less characteristic, lymphocytoid in- 
filtrations cf the mesenchymal supporting tissue of dif- 
ferent organs must be taken into account more than be- 
fore. In the central nervous system the specific sharp- 
ly defined foci prevail are the typical nodules of 
the exanthematic typhus. However, one must remember, 
that the distribution Of the virus throughout the body 
and the formation of such nodules is extended otfer a 
period of several weeks, so that besides fully developed 
small foci one also meets very incomplete foci and even 
capillaries with a distinctly altered swollen endotheli- 
um, cell desquamation, stasis or even thrombosis, and an 
edema of the adjacent vascular zone without a nodular reaction* Ihus the findings made on the brain.and the 
spinal odrfl'are more varied than one may have expected 
at first. 
Nevertheless the histological examination of the 
medulla oblongata, the brain and the cardiac muscle of- 
fer such clear histological results that the anatomical 
diagnosis cf exanthematic typhus can be made with cer- 
tainty: If during accommodation, attention is paid to 
all these signs the diagnosis is even possible, if the 
clinical picture is veiled or disturbed by a simultane- 
ous disease of a different origin. In mild cases the 
histological examination of the heart alone is not suf- 
ficient nor can a decisive diagnosis be made by micro- 
scopic inspection *f small pieces of the skin. In ad- 
dition to the general effect of the infection the 
alterations in the bulbar portion of the medulla 
gata must be considered as the usual cause of death. It 
was hinted above that disorders of the cardiac circula- 
tion must also be considered; finally the local results 
cf a disturbed distribution of the blood or secondary 
infections frequently play a fatal part, even if the 
central danger of the acute exanthematic typhus seems 
to be banned. Literature* 
BENDA: Histology of Petechial Exanthema* 
Wartime Conference of Pathologists Berlin 
1916, p. 43, 
CEELEN: Anatomy of Exanthematic Typhus# Ergebn.d# 
allg.Pathol.und patholog*Anatomie d.Menschen 
und der Tiere# 19*1 Abt# S.307, 1919 
CEELENs Anatomy of the Internal Organs During Ex- 
anthematic Typhus# Hdb#d*aerztl#Erfahrungen 
im WeTkrieg. Bd#8:Path#Anat.S.12?; 1921 
CEELEN: Histological Findings During Exanthematic 
Typhus Berlin Klin.Wochenschr#19l6: Nr# 20 
CEELEN: Projection of Exanthematic Typhus Preparations# 
Kriegspatholog#Tagung Berlin 1916. S. 14 
(Wartime Conference of Pathologists). 
DA1 YDOWSKIE: Pathological Anatomy and Pathology of Ex- 
anthematic Typhus# Erg.d#allg#Pathol.and 
Pathol#Anatomie d.Menschen u#d#Tiere 20: 
2# Abtlg. S. 723; 1924. 
FRAENKEL,Eugen: Pathoi.Anatom.Findings during Exanthematic 
Typhus# Muench.Med.Wochenschr# 1914; S.1534. 
GKUBER: Dtsch.mil.aerztl.Zeitschr. 1916; H.19/20, 
S. 402 
GRUBER: Cardiac Findings During Exanthematic Typhus# 
Zeitschr.f.Kreislaufforschung 34; 1942. 
HERZOG,Georg: Pathology of Exanthematic Typhus. 
Zbl.f.allg.Pathologie und patholog.Anatomie 
30; S. 97; 1918. 
HUECK: Importance of Histology for the Diagnosis 
of the Exanthematic Typhus# Leipziger Med. 
Gesellsch. 25. 11. 1941. Klin#Wo#1942;S.262. 
JARISCH: Cerebral Alterations During Exanthematic 
Typhus. Dtsch.Arch.f.Klin.Med.1926,H.3-9. 
MUNK, J: Clinical Studies in Exanthematic Typhus. 
Ztschr# f.klin.Med.82; H. 5 and 6. 
NICOL: Pathol.and Anat.Studies in Exanthematic 
Typhus. Bcitr.z.allg.Pathol.a.z.pathol.Anat. 
65; H. 1, 1919. 
RANDERATH: Pathoi.Anat.of Exanthematic Typhus.Lecture 
in the Institute of Hygiene in Warsaw. 21. 
January 1941, Med.Klin# 1941; Nr. 17 and 18. 
SCHITTENHELM: Exanthematic Typhus. Handb.d.Inneren Medizin. 
3. Aufl. 1. S. 965. Discussion: 
BOGENDOERFER: Prolonged transportation of the 
patient has a very disadvantageous effect upon the pro- 
gress of the exanthematic typhus• Therefore, it is not 
always desirable to admit all typhus patients to a common 
hospital in the rear, 3 days after the beginning of the 
continuous high fever transfer .from field hospitals to 
special hospitals in the rear should be made only under 
special conditions. In field hospitals and even in ca- 
sualty receiving stations small typhus wards should be 
organized from where the patients may be transferred to 
a special hospital after defervescence. 
HOLM; Since a long period of transport is dangerous 
for the patients, particularly when they are exposed to 
cold, it is necessary not to use only the big hos- 
pitals in the rear, but to attach typhus wards to the ad- 
vanced hospitals. 
GUTZEIT; Transportation has a detrimental effect on 
all highly infectious febrile diseases. This is the case 
with the exanthematic typhus and with dysentery. Eveja the 
most careful transportation should therefore be avoided, 
whenever the tactical situation permits it. Hence, in all 
hospitals and even in the advanced medical stations in- 
fectious disease denartments should be set up which must 
have enough room available so that patients suffering from 
exanthematic typhus can be kept there until at least 8 days 
after their defervescence. A premature transfer has an im- 
pairing effect even after defeverescence. From there the 
patients must be transferred to hospitals for convalescent 
patients until they have completely recovered. 
BOGENDOERFER asked about details on the decrease of 
the sodium chloride in the blood and suggests a diet rich 
in sodium chloride for patients suffering from exanthematic 
typhus. 
BERG; The importance of the occurrence of a deficient 
chloride state during exanthematic typhus is demonstrated by 
the therapy with repeated 5aCl infusions to which free Cl 
ions were added (before use the clorine water was freshly 
prepared and titrated iodometrically) employed by DANIELO- 
FOLU during World War I, before the hypochloremia was in- 
vestigated. At that time this procedure was considered as 
a decisive improvement of the almost fatal outlook for the 
untreated hypertoxic cases. This therapy a.ims at a con- 
trol of the cloropenia and we may expect from it that it 
improves the blood circulation during infectious diseases 
(' EIL!s icterus etc.) and presumedly also during exanthe- 
matic typhus in the same favorable way as during other chlo- 
roprivic conditions. 
KAUFMANN: Disorders of the sodium chloride metabo- 
lism are also suggested by symptoms similar to diabetes in- 
sipidus which appear towards the end of the fever period 
and disappear after 4 to 6 weeks. Inoculation during the 
incubation period reduced such a period. The further pro- 
gress of the disease, however, is favorable. GUTZEIT; It is necessary to come to an agreement 
as to which therapy should be applied to the circulation. 
In addition to a certain myocardial damage which is de- 
tectable by electrocardiographic examination only towards 
the end of the period of farvescence, or even after de- 
feverescence, but which clinically is not infrequently 
indicated early by a diffuse dilatation of the heart, a 
peripheral and a central insufficiency of the blood cir- 
culation is found. Hence, it is required to administer 
strophantin, glucose and sympatol at an early time, or 
veritol or veriazol, since a hypotonia is usually present. 
The centrally stimulating analeptics cardiazol and cormed 
should only be administered when there is a serious danger. 
HOLM: Recommends the use of calcium too ,(to con- 
strict the blood vessels, to influence the vegetative 
nervous system and, as a result, the blood circulation.) 
GUTZEIT: The clinical diagnosis must not depend on 
the serological diagnosis but efforts should be made to 
confirm the former by serological tests. A low WEIL- 
FELIX titer (about 1 : 100) excludes an exanthematic 
t3/phus just as little, as a high titer (1 : 800, 1 : 1000) 
confirms an exanthematic typhus. In areas of epidemics, 
abortive, latent and very slight cases of exanthematic 
typhus occur even with people who do not live there con- 
tinually (German soldiers), and they are not detected by 
clinical examination. High agglutination titers may be 
fbund with these, although they are not suffering from 
exanthematic typhus at the time of examination. Hence, 
during exanthematic typhus the agglutination shows the 
sane behavior as during all other infectious diseases. 
Therefore, the diagnosis of exanthematic typhus must be 
ascertained by clinical examination as was repeatedly 
requested for dysentery in this war. 
The numerous high Weil-Felix agglutination titers 
fourd with our men in the area of epidemics without 
pathological symptoms being present can only have two 
causes. Either there is a real non-manifest exanthe- 
matic typhus - which is likely - as with many such 
patients the rickettsia agglutination is positive too, 
or there are genuine proteus X 19 infections hereto- 
fore unknown to the clinical physicians, •which is possible 
since so many cases of intestinal impairment due to dysen- 
tery occur. At home investigations are being made which 
are concerned with the frequency of occurrence of the Weil- 
FHix titer in samples which were incidentally sent 
in for Wassermann!s and Widal’s reaction. Amongst 4000 
such tests performed prior to the middle of November 1941 
not one single positive Weil-Felix agglutination was 
found by MESSERSCHMIDT in Hannover. We are still wait- 
ing for the other results. 
KATSGH: During the Spanish epidemic of exanthematic 
typhus a very high percentage of typhus Ebert aggluti- 
nation was observed in the first days (with people who 
were not immunized against typhoid fever), before the 
Weil-Felix reaction became ‘positive. This shows clear- 
ly that no diagnosis should be made exclusively on the bas- 
is of agglutination titers. HOLM: wondeis whether conclusions as to the out- 
look can be drawn from the value of the Weil-Felix titer. 
SCHULZE: No such prognosis is possible. 
HOLM; asks what the results are of electrocardio- 
graphic records made during exanthematic typhus. 
GUTZEIT; The electrocardiograms are not so much 
required for an early diagnosis, as for the diagnosis of 
a delayed myocardiac impairment during exanthematic ty- 
phus. Most of the alterations occur only during the se- 
cond half of the period of fervescence. To estimate the 
fitness for service the electrocardiograms are indispen- 
sable. 
KATSCH; Is the development of necroses during ex- 
anthematic typhus enhanced by frostbites? 
GUTZEIT; The formation of a necrosis during typhus 
is frequently caused by the combined effect of pressure, 
cold, and circulatory disorders. A large number of nec- 
roses, however, was not observed. In addition to the 
necroses of the tips several extended necroses of the 
soft parts were observed (some of them on the thigh, 
the lumbar region, etc.), lisorders of the peripheral 
vascularisation by thromboses and embolism occurred fre- 
quently, but not regularly. The disturbance of the pe* 
riprheral vascularisation due to typical impairments of 
the vessels is sometimes sufficient to cause necrosis. 
HOLMs asks what the sick rate is of the immunized 
and non-immunized people. 
SCHULZE: According to WEIGL the sick rate is also 
reduced by the immunization. 
GUTZEIT; reports the possibility to make an eventu- 
al early diagnosis by the histological examination of an 
excised roseola. 
GUTZEIT; The opinion on the effect of serum ob- 
tained from convalescent patients varies greatly. Its 
supply caused often difficulties. Research in this 
line must be continued. To recognize its value exact- 
ly comparable investigations of alternating series must 
be performed in the same hospital. The same was hither- 
to valid for the blood of convalescent patients. Since 
in exanthematic typhus the Wassermann reaction may be 
positive late into the period of recovery, it is not 
required to make a Wassermann reaction of the donorrs 
blood prior to a blood transfusion from a convalescent 
patient. 
BRINKMANN, VOIGT and BOGENDOERFER are doubtful ss 
to the efficiency of the serum. 
HOLM reports of favorable experiences. 
VOIGT suggests to use Russians not as serum donors! DOLMEN: As to the favorable effects expected from 
blood transfusions during exanthematic typhus attention 
is directed to the results of the experimental cultivation 
of the viri. If the virus is fixed in the cells no in- 
fluence of antibodies on the virus can be observed. There- 
fore, if the exanthematic typhus has become manifest no 
influence can be expected from blood transfusions, where- 
as improvements may be observed as long as the virus in- 
vades the blood thus enabling neutralisation* 
GUTZEIT: As to the method of obtaining convalescent 
serum no unfavorable experiences were made in the hospitals* 
A blood transfusion from a presumedly healthy Spaniard 3 
days before he himself fell sick with typhus released an 
exanthematic typhus in the man who received the blood* 
KAUFFMANN: reports of the therapy with hyperthermic 
bathes according to LAMPERT; evidently they have a favor- 
able effect upon the blood circulation and considerably re- 
duce the seizures of excitation. 
KAUFFMANN recommends small doses of luminal (4* to 5 
tablets of O.olS Gr. daily) as a therapy against the fits 
of excitation. 
VOIGT disapproves the excessive use of narcotics. 
They impair the respiratory center* He also reports of 
good results obtained by the administration of small doses 
of luminal throughout the entire day* If during serious 
fits of excitability narcotics cannot be avoided, the ad- 
ministration of scopolamin-ephetonin-eucodal is advisable. 
SCHULZE: During an epidemic, besides temporary vari- 
ations of virulence local variations also occurred. With 
a constant material of patients in my hospital the death 
rate was: 
from October to December 1941 27.7 per cent 
from January to 28 Feb. 1942 7 per cent 
from March to 1 April 1942 25.0 per cent 
Definite differences of the seriousness of disease 
within the same area, time and unit were observed in two 
different hospitals where patients were admitted from 
the same unit which was assigned to guard various PW Camps 
at various places. 
HOLM: In the area of the 9th Corps the death rate 
was low at the beginning (2 per cent) but it was gradual- 
ly increased in the course of the winter (in the second 
half of April it amounted to about 12 per cent). 
VOIGT: The so called petechial form of the exanthe- 
ma tic typhus takes a particularly unfavorable course. This 
is the type of exanthematic tophus in which a hemorrhagic 
exanthem is present from the beginning on* Almost all 
of these cases are fatal. 
GUTZEIT: In the early stage it is hardly possible 
to give a prognosis on the outcome of exanthematic typhus. 
The lethality depends not only on the age and the locally and temporarily varying virulence of the rickettslae, but 
also an many other factors (transport, medical care, blood 
circulation, etc.). Therefore, the value or failure of a 
therapy can only be decided when the two factors of the£a- 
py gre given in the same hospital and are compared with 
each other. This is also valid for the hyperthermic baths 
used in Ostrow, the more so as the lethality as compared 
to other hospitals was considerably diminished - January 
and February 1941 (2 per cent)was increased again in Mareh 
to the death rate of other hospitals. The difference of 
mortality between the hospitals Warsaw II rnd Ostrow in 
the months of January and February range above the ex- 
pected incidental difference. 
GINS asks how many infections were caused by lice 
dirt. 
ZEISS warns against a premature publication of the 
results of the experiments concerned with infection by 
lice dirt and powdered lice dirt. 
SCHMIDT read a report of Oberstabsarzt (Major, MC.) 
ELLER on the infection with exanthenatic typhus where no 
lice dirt was found. Reference was made to the fact that 
such occurrences play no part for the majority of infec- 
tions occurring in the Army. 
HABS the first principle should always be that de- 
lousing controls the exanthematic typhus. Fear the front 
line delousing with hot air is sufficient. 
'• t 1. ' » . 
KLOSE: Hydrocyanid acid failed when used in PW Camps. 
VIERTHALER: It is certain that infections caused by 
lice dirt occur in PW Camps end are very likely there, par- 
ticularly when straw and wood shavings are used as beds. 
A continuous education of the PWfs to cleanliness and a 
constant delousing abolish the danget of infestation. 
MUGROWSKI; In concentration camps treatment with 
hydrocyanid acid was satisfactory. 
BIELING believes that in hospitals a constant dis- 
infection is advisable, as very good results were obtained 
by it. 
Does tobacco-extract prevent the infestation with lice? 
It appears that for use as a delousing drug nitigal has the 
same effect as the Russian K. soap. Delousing is the prin- 
ciple factor of the struggle against exanthematic typhus. 
Even if there are other possibilities of infection, delous- 
ing is the most successful preventive measure against ex- 
anthematic typhus. 
WOHLFEIL is of the opinion that prophylaxis from 
lice is more important. 
CLAUBERG reports of a procedure of delousing by a 
f1ow of hot air according to a new device which reduces 
the period required to kill the lice to 5 minutes. The 
heretofore valid rules for delousing could be modified so that only 20 to 30 minutes are requested for one 
single delousing. An elaborate technical scheme of 
this procedure will be drawn up in the near future, 
SCHREIBER: The problem of a prophylactic ad- 
ministration of lice powder was solved by the manu- 
facture of the Russla-lice powder. The previously 
used Cresol preparations are disapproved as they 
irritate the skin or fail against lice. By an ap- 
propriate delousing with hot air the rickettsia are 
killed with certainty. The danger of infection by 
lice dirt must not be taken too serious if there 
are no large quantities of it. If hydrocyan!d acid 
is disapproved completely, a successful disinfesta- 
tion of the PW Camps cannot be guaranteed. 
RODENWALD recommends by experiments 
the old Method of interring the garments except for a 
small end which should be left outside. 
LAUCHEs From the reports of the consulting me- 
dical officers and the inquiries it can be recognized 
that particularly the following problems are not cleared 
up yet and remain doubtful; 
1) Is the exanthema of the typhus histologically 
so specific that the diagnosis of an exanthematic 
typhus can be made vith certainty from a histo- 
logic examination of excised roseolae, as DIET- 
RICH asserted. 
2) Which organs, respectively which parts of 
organs should be examined histologically if it 
is desired to find typical granules with the ut- 
most possible certainty, 
3) Which is the final cause of death in exanthe- 
matic typhus? 
4) Does the exanthematic typhus take a fatal 
course in spite of protective immunization? 
From the reports available to me it is evident 
that 
ad 1, the exanthem, or the skin nodules often are not 
specific enough. This is my personal opinion. 
ad.2. According to most of the statements I think it 
is best to recommend the examination of the floor 
of the 4th ventricle, first of all of the area 
of the olivary bodies and secondly the heart. 
When death occurs, the nodules of the skin are 
usually no longer characteristic, or they have 
Vanished. Concerning the occurrence of the 
gliogenous nodules during exanthematic typhus, 
according to a verbal communication of HALLER- 
VORDEN, the statements of DA'TDO’ '3K.IE may be 
most reliable. According to these the forma- 
tion of the nodules begins in the first week of disease (in one case they were fully developed 
on the 8th day)* In the third week the process 
attains its culminating point, particularly on the 
16th, 17th and 18th day. In rhe fourth week a 
decrease is observed, but the nrocess still con- 
tinues until the 5th or 6th week. In the medulla 
oblongata the process becomes prominent on the 5th 
or 6th day of disease and it persists longer here 
than in the cerebral cortex, evidently not being 
finished by the 5th or 6th week of disease. Other 
statements are principally in accordance with 
these. According to them fresh nodules are found 
simultaneously with older regressing nodules. As 
to the specific properties of the exanthematic 
typhus nodules of the central nervous system it 
must be said that the Japanese encephalitis, the 
•St.Louis encephalitis, and the indigenous ence- 
phalitis described by PETTE may show the same 
type of nodules. All these types are implied by 
PETTE in the term Panencephalitis. However, 
these diseases differ from each other serologi- 
cally. (Upon ray request these statements were sub- 
sequently written down by H;.LLTCRVORDEI'T)♦ 
The myocarditis is often diffuse and in my 
opinion it cannot always be distinguished from 
a myocarditis caused by another disease, 
ad 3* According to the available reports death occurs 
as a result of the exanthematic typhus 'itself in 
■"'one half of the cases and it must be regarded as 
the consequence of central circulatory disorders 
which are often increased by the simultaneous oc- 
currence of myocarditis. In the other half of 
~ cases complications, and above all infectious 
diseases with a generally diminished physical 
resistance are the final cause of death (bron- 
cho-pneumonia c. oral infections such as diphthe- 
ria, tonsillitis, parotitis and sinusitis). The 
problem of how the necrosis develops is not yet 
solved, whether it be due to local causes such 
as decubitus, or to embolism, or to a specific 
impairment of the vascular walls, or of a cen- 
tral nervous origin. 
ad 4. Only 7 cases of death by exanthematic typhus 
in spite of immunization were hitherto reported 
to our collecting center. In two of these cases 3 
the immunization had not yet been completed, an 
other case wasa53 year old medical officer with 
a cornnary sclerosis, a further case was that of 
a medical orderly who on account of an erroneous 
diagnosis had received a Salvarsan injection. 
In a further case typical symptoms of exanthe- 
matic typhus appeared on the 5th day after the 
last inoculation, so that it must be assumed that 
at the time of inoculation the patient already 
was infected. Only one case permitted no proper 
explanation. 70 
ROESSLE refers to the diagnosis cf the exanthematic 
typhus. The dermal roseolae are not constant; they are 
irregular but specific when the disease is fully developed, 
SIEGMUND: The histological findings of the dermal ro- 
seolae depend upon how long they are present. The nec- 
rotic alterations given by FRAENKEL occur only during a 
certain stage of development. 
Under war conditions no diagnosis of the exanthematic 
typhus can be made from the roseolae, 
KOCH: The exanthema cf the exanthematic typhus cari- 
aOo always be distinguished from other exanthema* The ex- 
anthema of the exanthematic typhus shows a varying histo- 
logical structure. 
GRUBER: Gives one more suggestion as to the clinical 
diagnosis of the exanthematic typhus. Why should skin 
particles be excised, if the Weil-Felix reaction is re- 
latively reliable. One must not forget that a wound is 
caused by such an excision and that any complication of 
the exanthematic typhus should be avoided from well under- 
stood medical reasons, I am not surprised at all that the 
medical officers dislike to excise skin particles of theij 
patients suffering from exanthematic typhus, 
LETTERER: Diagnosis from skin excision is not certain 
to 100 per cent. The development cf the nodules depends 
on the time, that moans on the time' g|t which it was excised. 
KOCH: The best method of locating nodules at post 
mortem is to investigate the brain in the area of the oli- 
vary bodies and in the upper part of the rhomboid fossa. 
SIEGMUND: The examination of the brain stem (oli- 
vary bodies and rhomboid fossa) is the best method of 
a rapid diagnosis, 
DORMANS suggests to remove for an anatomic diag- 
nosis the cardiac muscle and the testicles in addition 
to the brain and to send them for a histological diag- 
nosis to a pathologic laboratory (since in the cases oc- 
curring in the 6th Army the heart and the testicles reg- 
ularly showed positive findings). 
RANDERATH stresses the frequent occurrence of a 
pronourced hemorrhagic gloncrulo-ncphritis during exan- 
thematic typhus. It is possible that they are inciden- 
tal complications occurring at a time when war nephritis 
is frequent. Reference is, however, made to these find- 
ings, since this glomerulo-nephritis occurring during ex- 
anthematic typhus was never diagnosed by clinical examin- 
ation. apparently because during exanthematic typhus no 
hypertonia occurs on account of a circulatory impair- 
ment, or because slight increases of the blood pressure 
which from the same reasons range below the normal values* 
In Russia a diffuse glomerulo-nephritis is seen in near- 
ly 25 per cent of the cases of exanthematic typhus. Hygienic Directions for the Prophylaxis of the 
Exanthenatic Typhus> 
The basis of any campaign against the exanthematic 
typhus is to exterminate the body lice* 
13 The epidemic distribution of the exanthenatic typhus 
depends principally on the occurrence of living body lice. 
2. The development of exanthenatic typhus is exclusively 
based upon infestation by dirt, (lice dirt), 
3c The exanthenatic typhus of the body lice is an 
intestinal disease in the course of which a large 
amount of highly virulent typhus germs are excreted. 
The fact that lice dirt is easily reduced to powder 
nay increase its dangerous effects. 
The disinfecting measures in areas infested or 
threatened by exanthenatic typhus must bo directed in 
such a manner that the body lice which arc the carrier 
of the germs causing exanthenatic typhus and, if possible, 
also the germs of this disease, the Rickettsia Prowazeki, 
are ’destroyed with certainty. Hereby it must be con~ 
sidered that an efficient disinfesting preparation is on- 
ly exceptionally a good disinfectant. The best prepa- 
ration for disinfestation is the hydrocyanid acid5 but it 
is no disinfectant, because it is not able to kill the 
germs. Nevertheless, for practical reasons? use is made 
of this compound. The same is valid for the mixed gas 
ventox-tritox, In hospital trains the use of sulphuric 
acid may be continued for the routine delousing for the 
tine being, 
5, The hot air delousing procedure meets the require- 
ments set up above, provided that the garments and ob- 
jects for delousing are hung up loosely and then are 
sufficiently heated* As a rule 90 degrees centigrade 
for at least 90 minutes are sufficient. Vaporous steam 
has a good disinfesting and disinfecting effect, if it 
is used properly. Leather goods and furs, however, can- 
not be exposed to it. The same applies to gas sheets 
and gas masks, 
6, Objects which will be spoiled by treatment with 
hot air had to be treated with chemicals, Cresol made 
water-soluble by an enulgator maintained its value. To 
delouse the body the use of a cleansing solution to 
which 2i cresol is added is recommended, 
7, The delousing of compartments by gases is success- 
ful only if the rooms are sufficiently sealed, (The use 
of hydrocyanid acid is only premissable by trained per- 
sonnel supervised by a responsible foreman). Straw 
couches and similar objects have to be burnd after use. 
Instead of the gas disinfection a disinfection by 
scrubbing the furniture, the walls and the floors to 
the level of 1,50 meters with a preparation of 2i per 
cent cresol is advisable. 8. Louse infected bandages applied for the fixation 
of bones, particularly all plaster bandages can only 
be changed by medical officers with a surgical train- 
ing. 
b) Trench Fever (Wolhynian Fever) 
Lecture by Obers ta'bsarzt (Ma jor, MG*')' Prof. BOGENDOEHFEH: 
Differences as opposed to the experience of World War I, 
Measures against it. 
Therapy. 
As is known, the disease is characterized 
1 € by a periodical fever, 
P« by a neuralgic-rheumatic syndrome* 
To speak of the disorders of temperature first, the 
following must be mentioned: ffiiere are most varied forms 
of the progress of the fever. Its characteristic feature 
is almost always its periodicity. As with malaria and 
with recurrent fever, periods of defervescence alternate 
with periods of fever. In the one type a nrclonaod period 
of defervescence is opposed to a short period of fever, or 
to a single deflection; in the other type, however, we found 
Periods of defervescence and periods of fever of approxi- 
mately the same length. 
As was known from World War I, we also saw to prin- 
cipal types of fever: 
1. the paroxysmal fever which drops immediately after- 
wards (paroxysaal type), 
2. the undulating form (undulating type). 
These two forms, however, can also be intermingled, 
so that at first no characteristic temperature curve seems 
to be present, and the diagnosis of Trench fever is made 
through the other clinical symptoms* 
Amongst our patients those with the undulating curves 
prevail. Then non-characteristic temperature curves follow. 
About one fifth showed the isolated high deflections of the 
five day fever* 
The deflections may be very transitory© In a field 
hospital where 120 patients suffering from trench fever 
were simultaneously present, I noticed that according 
to their temperature curves a great number of the patients 
seemed to be free of fever, when the fever was measured 
twice within 24 hours as usual. The two hourly measure- 
ment of the fever, in some cases made even at night, 
showed that a rise of temperature to even 39°C. was much 
more frequent, that was apprehended by only two measure- 
ments within 24 hours. The periodical fever may be very 
transitory. Upon myself I observed that within 3 hours the temperature rose to 39.6°C. and returned to normal 
again. 
the diagnosis of trench fever, therefore a 
Gontinuousf at least two-hourly,measurement seems ab- 
solutly necessary to me, all the more so, as for the 
substatiation of the diagnosis very few objective data 
are available. 
I mention this with a particular regard of the 
tracing of the responsible germs in the blood. In 
our army it was not possible even once to trace the 
Rickettsia quintana in the blood smear or in the thick 
drop" In our two bacteriological field laboratories and 
in the various field hospitals innumerable thick drops 
were examined and even in clinically unmistakable cases 
no formations were found, which could bo regarded as the 
germs causing the five day fever even if only a moderate 
scepticism was applied. If this is the result of tech- 
nical mistakes, I am afraid that these will occur else- 
where in the same way, at least under field conditions. 
No observations or data are available, which give 
information on the incubation period4 which according 
to the experimental experience allegedly lasts 14 to 60 
days. In two equal cases where two pen came from hygienl- 
cally incontestable surroundings the disease sot in with- 
in 9 days; from this observation may bo deduced that here 
the incubation period was 8 days. 
Prodromal symptoms are rare. According to our ob- 
servations the onset is acute. Shivering and headaches 
are th§ first symptomes. 
She rheumatic-neuralgic pains appear later, and 
they may consist of muscular as well as of osseous and 
articular pains of a very considerable degree, The most 
frequent type of pains are the wellknown tibial pains; 
but the complaints of pains in the bones of tho forearm 
are just as numerous. A tenderness of the calcansis is 
as frequent as of the sacral and the spinal bone. 
0f the musculature the calves are particularly af- 
fected. I also observed a pronounced painfulness of the 
abdominal muscles. 
The nerve trunks and tho nerve points arc frequent- 
ly sensitive to pressure; but no atrophy of the muscu- 
lature was observed though a particular attention was 
paid to it. However, we recurrently saw disorders of 
sensation, particularly hyperesthesias, most frequent- 
ly of the thigh. 
The general status is very often disturbed to a 
remarkably small degree only; the appetite is usually 
excellent. In a field hospital which was exclusively 
occupied by patients suffering from trench fever, weigh- 
ings were regularly made and without any exceptions 
a sometimes tremendous weight increase of the patients 
was observed. Not much can bo reported of changes of the inner 
organs. In very few cases - I believe not more than 
five - cardiac disorders occurred such as a subjectively 
disturbing tachycardia. It is likely that this is a toxic 
myocardial Impairment. 
As to the digestive organs a frequent occurrence of 
diarrhea was noticed* As intestinal disorders are very 
frequent in the Eastern countries, it is most difficult 
to decide whether there is a causal relation between 
these and the trench fever. Several times we saw sei- 
zures of pains in the right iliac region similar to 
appendicitis, without this being present. 
In some cases the splenic region is sensitive to 
pressure. But a distinctly enlarged spleen, was only 
found in about one fif:fe«u of our patients. No enlarge- 
ment of the liver was observed. 
As regards the urinary organs we occasionally found 
a febrile albuminuria, rarely a cylindruria, The diazo- 
reaction was constantly negative. 
No skin symptoms were remarked, he never observed 
an exanthema or a herpes labialis. 
The progress of the disease nay vary considerably. 
The cases in which the fever”*shows short moderatly high 
deflections, represent a light form of the disease. The 
number of attacks is sometimes very small. A case is 
known to me with only one single high attack of fever 
exceeding 39°C., which was followed by three smaller sei- 
zures of pyrexia at intervals of 5 days, whereupon the 
disease was apparently terminated. Most of the cases 
of the paroxysmal type are over after 6 attacks of fever. 
On the days where there is no fever the patients may 
be completely free from complaints and fit for duties. 
But those may be exceptional cases. 
The general health is more impaired by the prolonged 
febrile periods of the undulating form which was consider- 
ably more frequent.lv observed. In the majority of cases, 
however, here too**the fever disappears after 4 weeks and 
a quick recovery sets in* 
It is well known that some cases of this disease 
persist for a very long time® 1 refer to the literature 
where a report is given on a case which persisted over 
19 months. I believe that abortive cases occur net in- 
frequently. 
On the basis of .his experience in World War I, 
SCHITTENHELM mentioned a fever without any fever”. 
I fceli®va. too that the frequently occurring patho- 
logical conditions of strange osseous and muscular pains 
without fever must be attributed to trench fever, but on- 
ly when the periodically varying rheumatic-neuralgic 
symptom complex is present throughout several weeks. It 
seems to be remarkable that trench fever apparently oc- 
curs more frequently with the older men than with the youngest age groups* In the above mentioned field 
hospital which was occupied only by patients suffering 
from five day fever my attention was attracted first 
by the great number of non-commissioned officers among 
the patients. An accurate classification showed that 
only 3 men out of the 120 patients of this hospital 
were younger than 23 years. Although they belonged to 
a division with a normal average age which had even 
received fresh men of the youngest age groupso Further- 
more it was found that the comparatively smallest group 
of the five day fever patients consisted of infantry 
men. These were usually soldiers of units further in 
the reaf. Many gunners* men of supply units, members 
of the vetrinary companies and similar units were 
amongst them. Therefore one should not apply the 
term "trench fever" . 
I am of the opinion that the prognosis is favor- 
able. Nevertheless, the accumulated occurrence of 
trench fever may cause such considerable losses of the 
units that Measures against this disease must be taken 
not only for individual'reasons of treatment. 
The clothes louse is reputedly responsible for the 
infection with trench fever and its distribution. I do 
not know whether this is true. But i never saw a man 
suffering from this disease who had not had lice dur- 
ing the time of infection. The extermination of lice, 
therefore, belongs to the principal measure to be taken. 
Concerning the treatment cf the trench fever no 
experience is available of a successful therapy. I am 
bound to agree with SCHITTENHELM, who asserts, on the 
basis of the experience of World War I, that there is 
no specific therapy of the neuralgia fever. Frequent 
attempts with Fuadin were made. In one of our station 
hospitals where a small number of medical officers and 
nurses had fallen sick with the five day fever, fuadin 
was used, and one believed that there its use results 
in a success. In other hospitals, particularly in cur 
special trench fever hospital, no certain and convinc- 
ing results were obtained with the some therapy. lieo- 
sa 1 varsan (neo-arsphenanine) was also employedc. In some 
cases the fever disappeared after two injections,' in 
others it persisted. Ant In our a Ird. cs and pyranidon 
usually relieve the painsThis, however, is no caus- 
al therapy. The varying reaction of the patients towards 
the therapeutic application of heat is remarkable. Some 
of them welcome it, some of them reject it decidedly 
as increasing the pain* According to our experience 
the treatment can only be symptomatic. The drugs must 
,be selected individually* disease disappears 
also without any therapy. 
As to its name I want to mention that the tern 
"Wolhynian fever" may be justified for historical 
reasons bjit otherwise it hardly means anything. 76 
The term five day fever is misleading because it 
suggests a fever persisting throughtout five days. The 
tern given to it by SCHITTENHELM seems to ne the most 
correct: Febris neuralgica paroxysmalis sive undulans, 
or in short: Neuralgic Fever. 
Discussion: 
SCHULZE: 1. Morphologically and in the culture 
medium the Rickettsia quintana is identical to the 
Rickettsia pediculi. If man falls sick, one speaks of 
Rickettsia quintana, if not, of Rickettsia pediculi. 
By a repeated passage, however, the one form can 
change into the other. 
2. There is no answer to the following question: 
a) How long can the Rickettsia quintanae be found in the 
blood? (Detected even on the 23rd day of disease) 
b) How long is the blood of carriers of Rickettsia in- 
fectious? Neither agglutinins nor precipitins against 
the Rickettsiae bred in the blood of patients were 
hitherto detected. 
The above mentioned questions are principally im- 
portant, because there is the danger of further infec- 
tions when the patients return too early to their unit. 
SCHULZ: A frequent measuring of the temperature 
is also important for a differential diagnosis from 
malaria. The examination of a thick drop of blood en- 
ables such a diagnosis. 
CfUTZEIT: Heretofore it is not known, how long the 
Rickettsiae remain in the blood. As the general course 
of the disease is not serious, no isolation for 3 to 4 
months is possible. Therefore, the only way to struggle 
against this disease is a systematic delousing carried 
on also throughout the summer. 
Directions (leaflet) on the Trench Fever. 
"Trench Fever"(also called "Five-day Fever") is a 
disease which is characterized by the periodic occur- 
rence attacks ana a neuralgic-rheumatic syn- 
drome, and which for the first time occurred in a large 
number of cases during World War I on the Eastern Front 
and later on the Western Front (Flanders). Since this 
tine it has been studied in detail. , 
Cause: The Rickettsia quintana which lives as a 
parasite in the louse (distinguished from the Rickettsia 
prowazeki, which is the cause of the exanthematic typhus 77 
and only sticks to the surface of the intestinal epi- 
thelial cells of the louse). It is traceable by apply- 
ing healthy lice to persons suspected of trench fever. 
Epidemiology: It is a typical war disease* Its 
distribution depends on the degree of infestation with 
lice and therefore the climax of its frequency is at- 
tained during the cold season (February to May/June). 
It shows a tendency to an epidemic distribution which 
under given circumstances may considerably reduce the 
strength of the combat units. 
Incubation Period: Tery varyingj As long as 60 
days. 
Symptoms and course of the disease: Acute onset 
with a high fever, shivering or rigor without any pro- 
drome. General symptoms are lassitude, heavy limbs, 
headaches (fueling of oppression in the orbits and in 
the forehead), Vertigo, Rheumatic and neuralgic com- 
plaints, such as a painful condition of the extremi- 
ties, muscular pains and occasional articular pains 
(without local findings) occur, tenderness of the bones 
is typical, particularly of the tiblal bone* There is 
some tenderness of certain nerves at the foramina where 
the nerve trunk leaves the osseous channel and along 
the nerves , hyperesthetic and hyperalgic zones, dis- 
orders of sensibility as well as reflex anomalies* In 
addition a tenderness of the spleen occurs, which or- 
gan is often enlarged. The diazo-reaction is nega- 
tive* 
Blood-count: A neutrophil leukocytosis is fre- 
quent, while a relative lymphocytosis and eosinophilia 
is present during remittance and during the period of 
convalescence. 
The course is characterized by attacks 'of fever 
(4 to 6, even 12 and more) recurring in short inter- 
vals* The temperature curve shows two principal types: 
the paroxysmal and the undulating type* In the first 
case there is an interval free of fever of about 4 
days (which may be shorter or longer' between the tem- 
perature climax which persists for 24 to 48 hours, in 
the second case the fever is irregular, remittent and 
shows an undulating climax of temperature. There are 
rudimentary forms® Elevations of temperature of short 
duration are occasionally overlooked, if there is no 
two-hourly measuring of the temperature. After the 
disappearance of the attack - tie patients usually 
recover quickly. Occasional..1! a prolonged convales- 
cence is seen* 
Complications: Herpes jioralis (very rare),car- 
diac complaints of the angincus type with tachycardia, 
moreiarely a brady cardia. Ileocecal pains which 
suggest the erroneous diagnosis "appendicitis"* Secon- 
dary anemia. Differential diagnosis: 
a) Rheumatic diseases# Differential diagnosis by the 
anamnesia and the course of the diseases 
b) Leptosprlosis (Weil*s disease and swamp fever) Pains 
ot the tibial bonel 
c) Recurrent fever and malaria. Differential diagnosis 
by the microscopy diagnosis of germs in the blood. 
d) Dangfs disease (undulating fever of nan). Diagnosis 
by agglutination tests with the patient1s serum. 
Treatment: Symptomatic. Antineuralgics, particu- 
larly pyramidon and novalgin, occasionally had a good 
result. Antypyretics generally have no influence. 
In rudimentary cases, when the disease is about to 
disappear the oral administration of arsenic is advisable 
(Pil.ferri-arsenicos containing 0,05 As). It may also 
be employed as a stimulating drug during convalescence. 
The administration of convalescent serum or blood 
of convalescent patients is recommended but in any case 
of blood transfusion and examination of the donor*s blood 
for lues is required • 
Personal and general prophylaxiss Trench fever is 
the more numerous the greater the infestation with lice 
is. Delousing eliminates its base. For necessary meas- 
ures see H.Tv. 194 (Army Regulations on disinfection and 
disinfestation ), 209/XIX Directions as to the possibili- 
ty of delousing , 209/2-100 Directions as to exanthematic 
typhus and Military Hygiene during Winter”)• 
c) Recurrent Fever. 
1. Lecture by Oberfeldarzt (LtoCol.MC,) Prof.RODENWALDT• 
Characteristic symptoms? The recurrent fever is 
practically never diagnosed on its onset but always at 
a later time. To recognize it , it is necessary to ob- 
serve the temperature curve for a couple of weeks, if 
the principal symptoms are not known from personal medi- 
cal experience, and if there is no possibility of examin- 
ing a fresh blood smear. 
As a principal symptom may serve the feeling of be- 
ing seriously ill which is present subjectively and ob- 
jectively from the first day on, Simultaneously an epis- 
taxis, sometimes only petechial hemorrhages occur, secon- 
dary infections (pleurisy) arc frequent. 
Diagnosis: The examination of a fresh blood smear is 
obligatory if a microscope is available. Then the Spiro- 
chaetae recurrentis are visible in the blood, even with- 
out immersion. They are easily stained with methylene 
blue or eosin. It is important to bear in mind that 
this simple examination should be made even during the intervals free from fever, since the Bpirochpetae 
can be present in the blood even if there is no- 
pyrexia. 
Therapy: 0.45 salvarsan eliminates the patient 
as a source of infection. This therapy is successful, 
if the salvarsan is administered during or after an 
attack of pyrexia. Attention must be paid to the 
fact that the recurrent fever can be completely hidden 
behind an exanthematic typhuso Patients suffering from 
an exanthenatic typhus must by no means be treated with 
salvarsan. 
The Spanish recurrent fever and the Sprionema 
Ottoni (East Africa) cannot be treated v.ith salvarsan. 
2. Lecture by Oberfeldarzt (Lt.Col.MC).Prof• KOCH. 
The anatomical picture of the recurrent fever is 
not so characteristic that a diagnosis can be made with- 
out further ado. This is very easy when the Spirosomae 
are traced. 
i 
The spleen sometimes shows changes which suggest 
recurrent fever. It is enlarged and allegedly attains 
three times its normal size. A great number of nec- 
roses frequently is seen which simulate a miliary tuber- 
culosis. Moreover single or numerous infarcti ns are- 
observed in about 50 per cent of all cases. The in- 
farctions burst and even cause a rupture of the spleen 
and may perforate into the abdominal cavity when pus 
was formed as a result of secondary infection. 
A swelling of the liver with necroses occurs con- 
stantly. Necroses allegedly are also present in the 
bone marrow. The kidneys may be affected too by de- 
generation and inflammatory processes. 
The cerebral findings are important for the clinic- 
al symptomatology of the disease. A serous or a sero- 
fibrinous meningitis with many leukocytes is observed in 
connection with a cortical encephalitis and must be 
traced to the recurrent fever itself, as Spirosomae 
were found in the meningeal vessels. 
There are reports of a hemorrhagic type of the 
alterations due to recurrent fever. Dermal, intestin- 
al, and meningeal hemorrhages and those of the bone 
marrow were mentioned. It is not known yet, whether 
they are the consequences of the Splrosoma infection 
itself, or whether they are caused by simultaneous 
diseases such as 'tuberculosis, dysentery, sciurvy 
and others. 
Recurrent fever has a particular tendency to se- 
condary infections. Pneimcnic processes of all types 
are found in the lungs and, as a rule, they are the 80 
cause of death. Moreover, however, septic pyemic 
processes are a frequent complication. Pyodermiae, 
abscesses of the organs, excretory foci, parotitis, 
pericarditis, and myocarditis must be mentioned, in 
the pus of these organic foci no Spirosonae are found. 
These specifically pyemic changes are probably the 
basis of the symptom complex of the bilious typhoid 
fever which is characterized by a considerable icter- 
us and serious conditions of coma, if no real typhoid 
fever or Weilfs disease are present in addition, since 
the recurrent fever may freque' tly occur together with 
other infectious diseases, sudh as diphtheria, exanthe- 
ma tic typhus, malaria, and others. Attention must be 
paid that in accordance with other organs having an 
abundant content of reticulo-endothelium, such as the 
spleen and the bone marrow, the liver is regularly 
subject to a primary impairment by the Spirosonae 
recurrentis. in these organs the Spriosomae are killed 
by lysines and they are phagocytized by the reticulo- 
endothelium when they are necrotic. 
Further autopsies of patients who died of recur- 
rent fever and of material resulting from obductions 
are desirable so that a constant anatomical survey 
can be obtained. 
Discussion* 
REX* In addition to the infarctions of the spleen 
which are underlined by Dr. KOCH, a particular emphasis 
should be laid on the diffuse follicular necroses of 
the spleen. The association of larger infarctions to 
numerous small follicular necroses nay be apt to suggest 
the presence of a recurrent fever. 
DORMANNS* Attention is called to the fact that 
PONFICK described follicular necroses of the spleen as 
characteristic for recurrent fever. 
Two cases of extensive follicular necroses of the 
spleen in Charkow raised extended investigations of the 
recurrent fever. However, it was never possible to 
trace Spirochaetae in these two cases. Examination of 
thick drops attained from suspected cases, made upon 
frequent suggestions, were not successful in the hospi- 
tals of the 6th Army before 20 April 1942. Since, ac- 
cording to Russian reports, the number of cases of re- 
current fever in Russia has deopped from 400 000 to 
2000 per year during the last decades, which would a- 
gree with our observations, no serious attacks of re- 
current fever are expected. 81 
VII • 
BACILLARY AND AMEBIC DYSENTERY. 
(ANNEX: CLEANING OF FRUITS) 
Translation prepared by: 
Office of Military Government for Germany (U. S.) 
Office of Naval Advisor, 
Medical Secti n. a) Bacillary Dysentery. 
1. Prophylaxis. Therapeutic Aspects. 
Qberstabsarzt (Major, MC.) Prof, AS3MANN. 
In spite of all pains bestowed on it the control 
of dysbntery is still the most difficult task compared 
to other war epidemics® The reason for this nay be 
seen in the fact that the germs causing bacillary dysen- 
tary which under certain conditions occur regularly dur- 
ing the late summer and autumn are found almost every- 
where sc that the isolation measures successfully ap- 
plied against other epidemics are hardly effective. On 
the other hand, the immunization against dysentery can- 
not compete yet with that against typhoid fever and 
cholera concerning effectiveness as well as harmless- 
ness. 
Theoretically one could imagine that the early 
diagnosis and isolation of the very first cases might 
prevent a further spread of the disease. Dysentery, 
however, is endemically distributed throughout the po- 
pulation of the territories where fighting took place, 
particularly of the Eastern Front. Moreover, numerous 
bacillary carriers might be with the troops who fought 
on several war theaters. When the first cases of dysen- 
tery are reported by a unit, one usually learns that 
similar cases have occurred almost simultaneously in 
other units. Some of them are severe cases with hemorrha- 
gic diarrhea and violent tenesmus, some of then arc 
slight cases with a slight diairhea with no blood ad- 
mixed; some of them are disguised as transitory gastric 
disorders in which cases the assumption even that this 
might be a case of dysentery immediately provokes a 
brisk contradiction. Particularly in those cases the 
practitioners used to make the strictest theoretical 
demands and to request a bacteriological diagnosis 
before taking practical measurements. As a result 
of the well known difficulties of the bacteriological 
diagnosis of dysentery this will take such a long 
tine that in the meantime the epidemic of dysentery 
will be fully developed. As a matter of fact, on the 
basis of serologic investigations we must assume that 
the dysentery causes not only tne well-known and most 
feared serious symptoms, but also occurs in a slight 
form as a scarcely noticed gastro-intestinal disorder. 
During every autumn we see that the number of persons 
with an abnormally increased agglutination titor is 
steadily increased with the course of tine, even if 
only mild symptoms of disease had preceded. Here, I 
refer to the informations which I received from cur 
consulting hygienist Prof. Dr* BAGHMANN during the 
French as well as during the Russian campaign* It is 
however, quite incompatible with the military re- 
quirements to give these people the sick status and 
to isolate then, if they report sick in a large 
number. 
Contrary to this, it is quite possible, and ac- 
cording to my opinion, even necessary to isolate the dysentery patients and the suspected cases of dysen* 
tery within the hospitals and the casualty clearing 
stations from the patients not suffering fron intestin- 
al diseases. 1 observed quite avoidable contact in- 
fections in the snae rooms in places where these regu- 
lations were not carried through in spite of strict 
orders. 
I believe that the most important prophylaxis 
against a further spread of dysentery is to build 
hygienic latrines and to fill them up with earth when 
leaving, and to remove the garbage and to cover it 
with earth. While the building and cleaning of the 
latrines is at least theoretically accepted by the units, 
although fron evident reasons it is not everywhere 
carried through, a removal and covering of the garbage 
is accomplished only in few places in a really careful 
manner. I visited military hospitals which otherwise 
were maintained in a perfect order and only complained 
of an infestation with flies, asking for remedial measures; 
but if ante inspected the back side where the cookhouse 
was, one noticed almost everywhere that the garbage was 
thrown into open pits or was lying around. These are 
breeding-places for flies which first of all have to 
be considered as the ccntaminators of dysentery. There, 
protective measurements must bo taken. 
Further prophylactic measurements endeavor to pre- 
vent an invasion of dysentery bacilli into the human 
body by means of specific preparations (immunization), 
by bactericidal living material (phages), or by in- 
creasing the general resistance of the body. 
The results of the immunization are estimated 
differently. Since I noticed in the order of the day 
that a special report on the immunization and the bac- 
teriophages is prepared by the consulting hygienists, 
I want to refer to this, the more, as I have no per- 
sonal experience of the conditions in the operative 
theatres. In the iirmy District No. I no distinct dif- 
ferences between the course of the immunized and non- 
immunized cases of ■ disease were observed by the 
consulting medical specialist Prof. H;JMTSCHH;aNN, who 
is the deputy director of my clinic. However, numerous 
sequelae of immunization were observed by him such as 
abscesses in the thoracic area, some of which wore 
sterile or contaminated with bacteria. 
pie experimental, prophylaxis with bacteriophages 
is not impeded by such disagreeable by-effects, but 
its results are not made sure yet. Some of the reports 
on that matter, however, must be considered as encourag- 
ing. It is. of course, required to prohibit drinking 
unboiled water and eating non-peeled, dirty fruits. 
I consider the following general measures of 
prophylaxis ivhich are to prevent a decrease of the 
resistance, as very important and, for the time be- 
ing, as equal or superior to the measures aiming at 
preventing the distribution of the bacteria*. These neasures consist of a protection against 
chill and drenching and particularly they are to 
keep the body warm. During World War I as well as 
during the campaigns in Poland, France, and Russia 
I observed repeatedly that epidemics of dysentery 
occurred after a prolonged heat-period in summer, 
but usually hot during this period but after it was 
succeeded by a sudden drop of temperature, a heavy 
rain, and a considerable drop of temperature* The 
easiest explanation of this peculiarity may be that 
the dysentery bacteria were widely distributed dur- 
ing the heat period and that the sudden falling ill 
of a large number of people was caused by their 
decreased resistance which was the result of a 
sudden cooling down. As far as the possibility is 
given which is not always the cavSG during war but 
can be provided frequently, efforts should be made 
to pass the nights in quarters which are protected 
against rain and cold, such as tents, and above all 
to put on abdominal protectors before going to sleep. 
The French troops, particularly the colonial troops, 
always made use of such, YJhen a considerable number 
of abdominal protectors was captured from the French 
during the campaign in France, I tried to fill up 
our stocks and to provide cur soldiers with them* 
These measures are particularly important in regions 
where a considerable t emperature difference between 
day and night occurs, that means«, when there is a 
continental climate,'as in Russia and #*f??loa, They 
are less important for the Atlantic climauo the 
western countries# 
During epidemics food poor in fat but richt in 
carbohydrates should be given such as noodles, rice, 
and semolina# 
The most efficient therapeutic and prophylactic 
measures are heat, diet* and a careful nursingo The 
principal thing in the treatment of dysentery is not 
to employ new drugs, but t: observe carefully old and 
approved principles * 
This is done in the best way in special hospitals 
and hones for convalescent patients* In Poland and 
Russia I made the best experience with this system# 
However, the special dysentery hospitals should 
not admit the patients of a too extended area# For, 
serious cases of dysentery should by no means be trans- 
ported over a wide distance# The special dysentery 
hospitals must therefore bo as close to tho front as 
possible, and special quarters must be provided in 
addition in all military hospitals, casualty clear- 
ing stations etc* for those cases which cannot be 
transported# Homes for convalescent patients, how- 
ever, to which these patients are transported who 
have regained a certain strength, may be installed 
more to the rear# The life of many dysenteric pa- 
tients depends far more on avoiding an exhausting transport than on the application of any medicament. 
Compared with these general measures all other 
things are of minor importancec The following must be 
mentioned; 
1. Intravenous or intramuscular therapeutic ad- 
ministration of immune serduring the initial stages 
of serious cases. In general it seems to be quite 
efficient, but a reliable estimation of the success 
is difficult as in stages of danger serum is regular- 
ly administered for good reasons a Hence, no compari- 
son is possible with similar casesc 
2. One single dose, but by ro means continued 
administration of laxatives such as castor oil. A con- 
tinuous administration of castor oil must be avoided, 
as the body is severely weakened by it. 
3. Dessicated patients will be treated with 
sodium chloride and tutofusin infusions and with blood 
transfusions * 
4. Intake of sodium chloride with the food, if 
necessary the intranvenous injections of a 10$’ solution 
of sodium chloride are triven to retain the water taken 
in and to prevent it from flowing off, 
5* A careful control of the cardiac function and 
the blood circulation, particularly the treatment with 
strophantin when cardiac failure is imminent or present. 
6. A'W'.'^yne and antispasmodic measures when there 
are colics and tenesmus. 
Any other treatment will not be mentioned here, 
since I must assume that it is either known or less im- 
portant. 
To form my personal opinion about various drugs re- 
commended by many people 1 m.ade the following arrange- 
ments, when during the present Russian campaign a dysen- 
tery hospital was established at Hungerburg according to 
the principles laid down by GUTZEIT; In three of its 
departments, each of them being supervised by a medical 
officer, half the number of patients received no special 
treatment, except the usual special diet and application 
of heat; of the other half care was taken by certain 
measures. The patients of Department I were treated 
with Eubasin which was particularly recommended by 
the young medical officers; to those of Department II 
dysentery phages were administered and in Department 
III the treatment consisted of an apple-diet or Aplona. 
This separation of the departments was made in order to 
avoid that the patients receiving a differing treatment 
become suspicious. During my visits in this hospital 
every few days I found no noteworthy difference between 
the treated and untreated cases. Only Eubasin had often 
a disagreeable effect on the stomach which is known from 
its use in cases of pneumonia. Therefore. Eubasin was 
soon abandoned. Later on, when on account of my trans- fer deep into Russia. I was no longer able to visit 
this dysentery hospital frequently, the view of the 
medical officers was slightly different* Then they 
believed that the additional treatment with phages 
as well as with Aplona had some effect; but they were 
not able to produce any objective evidence* 
This shows how necessary a critical attitude is 
towards therapeutic measures. But the criticism must 
not be exaggerated to scepticism and as careful as I 
am in estimating the above mentioned medicaments, so 
firmly am I convinced of the decisive importance of 
the first mentioned therapeutic measures : heat, 
special diet, and nursing, furthermore infusions when 
the patients were desiccated and weak. 
Complications of dysentery are frequent, particu- 
larly when the epidemics contihue for a long period; 
they occur even in slight cases. A complete or in- 
complete Reiterfs symptom complex is often seen but 
sometimes it is misunderstood at first and only a 
careful anamnesis and an agglutination test reveal 
the dysentery which had been overlooked, but which 
had preceded in all these cases. Almost all of the 
complications, however, took a favorable course with 
a symptomatic treatment even if they were of a long 
duration. Cases of chronic dysentery resulting in 
severe cachexia were noticed by me far more rarely 
now than during World War I. This may be due to the 
fact that v;ithin my sphere of activity the Eloxnor and 
E-dysentery were principally found while the Kruse- 
Shiga dysentery occurred only occasionally. In such cases 
blood transfusions should be made, which have a-non- 
specific effect. 
The main principles are summarized as follows: 
1) Prophylactic measures: 
Protection against chill and drenching, Abdominal 
protectors. Distribution of food rich in carbohydrates 
but poor in fat, when cases of diarrhea occur frequent- 
ly* 
Careful building of latrines and filling them up 
with earth. Removal of the garbage. 
Concerning immunization and the prophylaxis by 
use of phages I refer to the report of the hygienist. 
2) Therapeutic measures. 
Heat, special diet and careful nursing are a? 
necessary as an accurate control of the heart and 
the blood circulation; if these are impaired, treat- 
ment with Strophantin, in cases of desiccation in- 
fusions of any kind are required. 
The application of dysentery serum? principally 
intravenously, is recommended in the initial stage of 
severe cases, although its effectiveness is not so sure. 
Exhausting transports of dysentery patients should be 
avoided. 2♦ Immunization, bacteriophages (Preservation and 
transport). 
Kriegsarzt Dr, VIEHTHALEH. 
c 
The immunization against dysentery was prepared 
for this summer so that the largest part of the Eastern 
Army will be actively immunized. 
The following vaccines are available: 
A) Vaccine of the Behring Works s A polyvalent Formol 
vaccine containing a Shiga-fraction of about 20 per cent. 
B) Serum ’’Zeiss” of the Hygienic Institute of the Uni- 
versity of Berlin: a polyvalent Formol vaccine con- 
taining 40 per cent Shiga germs* 
C) A Shiga-Formol vaccine according to OTTEN without 
dysentery germs poor in toxins. This serum is given 
simultaneously with the oral Entero-vaccine ’’Dysperos” 
of the Behring Works. 
D) Aldystox, which is a Combined adsorbing vaccine of the 
Behring Works. 
Concerning the quantity, the sera mentioned under 
A) and B) form the largest part of the material avail- 
able for immunization. OTTEN1s vaccine which is given 
simultaneously with the Entero-vaccine and Aldystox are 
employed only to a minor extent. The immunization is 
made in a comparable way so that a good survey about 
the effectiveness of the various vaccines available to 
us will be obtained by the end of the summer© 
The relatively large portion of ihe Shiga-dysen- 
tery germs contained in the Formol vaccine of the Hyg- 
ienic Institute was chosen because of the well-known 
fact that the Shiga dysentery relatively frequently 
shows severe forms and the revival of a Shiga epidemic 
cannot be excluded with certainty® 
The Formol vaccine with which the largest part of 
our Eastern Army will be immunized was previously tested 
as to its tolerability: It shows no considerable local 
or general reactions as are usually seen with other 
vaccines such as the typhoid fever vaccine. 
Phages. Opinion on the success of the prophylaxis 
and the therapy with dysentery phages differs consider- 
ably. A supply of the dysentery phages to the field- 
army for the purpose of prophylaxis is impossible, as 
the transport problem is extremely difficult. To yiell 
sufficient results larger quantities of phages have to 
be given and several 10 000 kgm. have to be transported 
to the units to supply only a small part of the army. 
Naturally, this is not possible for the time being. 
A Special Department of the High Command (OKH) charged 
with the control of epidemics was ordered to produce 
specific phages at the places of operation in the East- 
ern theater and will investigate this problem thorough- 
ly a second time.  Confused and Disputed Problems of Pathogenesis» 
Oberstabsarzt (Major. MC.) Prof, LETTEHER* 
The attempt to regard the bacillary dysentery 
from the point of view that explains the entire patho* 
genesis causes difficulties • Apparently, the sympto- 
matology of the disease, the behavior and the way of 
the gems through the sick body and the anatomical 
changes seem not to be in accordance with each other* 
As impressive as the anatomical picture nay be 
during autopsy - it is, as a matter of fact , no equi- 
valent of the seriousness of the disease and of death; 
this is demonstrated by a fatal outcome of the dysen- 
tery within the first days of disease with very slight 
anatomical alterations of the intestines and even more 
by those cases with symptoms which have much improved 
clinically or have almost disappeared and who dying 
unexpectedly still showed a severe necrotic enteritis* 
Therefore, the pathologists referring to this question 
as to death from dysentery assert that it results not 
always from morphological damages of the colon} how- 
ever, nobody denies that an intestinal damage and its 
consequences may sometimes be the cause of death* 
When comparing the biological, toxic and chemical 
properties of the germs, no full accordance is deter- 
mined between these and the anatomical alterations of 
the intestines which are uniformly and constantly 
found with all cases of dyserntery* There are differ- 
ences of the properties of germs which result not in 
an anatomical equivalent* Biologically, that means 
with regard to the formation of toxins (ecto-and endo- 
toxins according to Shiga and endotoxins according 
to Flexner and Kruse);, and probably with regard to 
the chemical structure of the toxins (protein nature of 
the ectotoxin, polysacharld-lipoid nature o.p pure 
polysacharid nature of the endotoxin) the species 
are doubtlessly different; on the other hand it is 
not possible to differentiate anatomically cases of 
Shiga dysentery from Flexner or Krusc-Sonne cases; 
the latter seems particularly important to me as we now 
know that the Kruse-Sonne endotoxin is a pure poly- 
saccharid. Cases of Kruse-Sonne dysentery dissected 
during the epidemic in Heidelberg showed no difference 
from the usual findings during dysentery (statement of 
Prof. SCHMINCKE)* This discrepancy should solve cer- 
tain doubts as to the correnctness of some ideas a- 
bout the pathogenesis, since here the same anatomic- 
al picture is formed by apparently different sub- 
stances, or their effects. 
The Shiga bacillus which simultaneously produces 
a genuine neurotropic toxin and an enteroptropic endo- 
toxin secretes directly the formed ectotoxins and causes 
an impairment of the body by them. Its ectotoxin 
allegedly is neurotropic only and has no impairing 
effect on the intestines* To my opinion this is not 
decided yet and I hold it certain only if dysentery caused by O-forms which contain no endotoxin is 
proved experimentally and anatomically which in 
this case must not be accompanied by necroses of 
the mucous membrane of the intestines. As to the 
assumption that the ectotoxin of the Shiga bacil- 
lus is purely neurotropic, one must remember that 
there are cases of Flexner dysentery with a rapid- 
ly fatal outcome that means that they cause a pure 
endotoxin injury, which showed very slight intestin- 
al alterations with minimal crust. 
Things are different with the germs of the 
Flexner and Kruse-Sonne types. Here the toxin can 
only come into effect, if the germs have died. But 
where and why do they die and in which way is the 
body affected by this toxin? 
These problems become more distinct, if one 
traces the way of the germs and compares the course 
of the dysentery with that of the typhoid fever which 
is also an infectious disease of the intestines. The 
assumption that the route of infection with dysentery 
is through the anus may now be considered as wrong 
and the oral way of infections may be the meet frequent 
in the cases of typhoid fever and dysentery. After pas- 
sing the oral cavity, the esophagus * and the stomach 
(relatively acid-proof germs, importance of gastric 
anacidity) the germs of typhoid fever and of dysentery 
arrive in the small intestine and behave differently 
there. While the bacilli causing typhoid fever are 
resorbed in the small intestine, which is of a deci- 
sive importance for the general distribution of the 
germs in the form of a typhoid fever septicemia, the 
dysentery germs are not or only exceptionally found 
in the blood. There is the problem of whether the 
dysentery germs are unable to pass through the intes- 
tines or whether they are immediately destroyed in the 
blood and thus cannot be demonstrated. As to the ty- 
phoid fever the latter is not likely, for, while with the 
typhoid fever the growth of the germs in the blood and 
in the spleen is the reason why defensive reactions of 
the body consisting of agglutination on the one hand, 
and a swelling of the spleen on the other hand set in 
these symptoms are not found with dysentery; a swelling 
of the spleen is rarely found, an agglutination reac- 
tion is absent in most cases. 
While the spleen having the largest surface of 
the mesenchymal organs of defense reacts on the germs 
of typhoid fever to be killed and their endotoxins by 
a large soft swelling which is caused by a voluminous 
formation of pulpa cells, the dysentery progresses with- 
out an enlargement of the spleen and any reaction^of the 
pulpa. The spleen remains small and hard, hence it may 
be concluded that no noteworthy bacteriemia occurs. If 
this is not present regularly, measures destined to save 
by a prophylactic humoral resistance against the germs, 
such as the immunization against typhoid fever, do not 
promise the same complete success in the case of dysen- 
tery as they do with typhoid fever. 90 
Here, a comparison with diphtheria is permissable# 
*There too, the bacteriemia is slight except for some 
few findings# The formation of ectotoxins by the germs 
stands in the center of the pathological effects; here 
too, the spleen is usually small and hard, here too 
crusts are formed on the epithelial surfaces, and here 
too. there is a full success of the therapy with a anti- 
toxin and of thenethods of a prophylactic treatment with 
antitoxin# In my opinion it is no mistake to regard 
dysentery as an intestinal diphtheria, not only from the 
anatomical point of view, from which it is seen as a so- 
called diphtheric inflammation, but also from the patho- 
genetic point of view. Under this aspect one should ex- 
pect that for dysentery too, the treatment with anti- 
toxin is the adequate method. 
The excretion of bacilli of the typhoid fever with 
the bile results in a return of the germs in the intes- 
tine, the resorption through the mucous membrane occurs 
for £he second time and during the.first process of re- 
sorption the germs passed the intestinal wall without 
causing a noteworthy alteration it reacts at the second 
time with an attempt to block the resorption, which is 
morphologically expressed, in a medullary swelling of 
the lymphatic organs, oince the development of such 
a reaction hyptrergy-pathargy), takes a cer- 
tain time the incubation period of the typhoid fever 
can be regarded as the manifestation of the time factor. 
In this regard things are different with dysentery. Its 
incubation period is considerably shorter, and? under 
these circumstances, we wonder what the mechanism of the 
development of its clinical and anatomical symptoms is. 
The bacteriologists believe that these problems are al- 
most settled as it is a fact that the dysentery toxins 
have an enterotropic effect. A similar tropism alleged- 
ly occurs with the diphtheria too. Since the investi- 
gations of DOPTER (1903/06) and particularly since the 
excellent studies of DOERR on the Shiga toxin in 190?, 
there is no doubt that Shiga toxin given subcutaneous- 
ly in animal experiments may provoke a serious dysen- 
tery on the colon of rabbits in the same way as does 
the infection of a broth culture medium of the germs 
themselves. A direct injection of the germs into the 
colon, however, causes no dysentery when the rabbit is 
healthy, DOERR concludes from these observations that 
the toxin is secreted from the colon and that it in- 
jures the mucous membrane in a similar well-known wQy 
during this process of secretion as does mercury and 
other metal salts when they are secreted through the 
colon. If one evaluates these experiments critically 
one^may ask whether the quantities of bacteria and 
toxins used during such investigations are approxi- 
mately the same as the quantities playing a part dur- 
ing the actual process of disease and whether the dos- 
es applied are not considerably too high# In the case 
of the enterotropic endotoxins the gsrms must first 
be killed in the intestine before their toxins can be 
resorbed. But in which parts of the intestine will 
this resorption take place and in which of its sec- 
tions are the dysentery bacilli killed? Is in'Jthts case the colon the organ of resorption and 
secretion simultaneously? DOERR demonstrated that the 
small intestine has a specific function to neutralize 
the Shiga toxin; hence, it might be resorbed there 
too, but then the germs would grow in the small intes- 
tine rather quickly and secrete their toxins through 
the colon, where they were carried by the blood* Noth- 
ing is known of these processes, neither of a possible 
growth of the bacilli in the small Intestine nor why 
as bacilli they are apparently not resorbed at all. 
It must be left open whether this is the only possible 
explanation* With regard to therapeutic measures it 
is desirable to elucidate this problem* 
For the pathologists the regularly ascending ten- 
dency of the intestineal alterations is particularly 
conspicuous. It is difficult to bring this in accord- 
ance with the conception that the mucous membrane is 
injured by secretion of toxin, as this is supposed 
to be a diffuse and constant process. Local processes 
must also play a part here; even VIRCHOW referred to 
a retarded motility at the curvatures of the intes- 
tines, which enables an increased effect of the toxins 
there* If one assumes that the dysentery bacilli, which 
rent into the small intestine through the mouthy grow 
there and are killed in the large intestine by the in- 
fluence of the bacteria (Coli), bacteriophages present 
there, and by the changed chemism of the intestinal 
fluid, the development of the anatomical damages can 
also be explained by a local effect of the toxin with- 
out that there is any reason to contest the resorption 
and excretion of the toxin as an additional symptom* 
The progressive thickening of the intestinal chymus and 
• a certain decrease of the intestinal motility towards 
the sigmoid and the rectum would explain the increased 
toxic effect towards the terminal parts of the intes- 
tine* To elucidate these questions particular atten- 
tion should be paid to the conditions in the small in- 
testine. According to DOERRf s studies one may assume 
that the Shiga bacilli are able to produce toxin in 
the small intestine, but that the mucous membrane is 
indifferent against it due to a mechanism which binds 
the toxins. There is no excretion of toxin with the 
bile, as was also demonstrated by DOERR* Direct and 
indirect toxic effects are summed up in the colon* In 
this case, the toxic effect of the endotoxin w/ould de- 
velop only in the colon where the destroyed bacilli 
are and the seriousness of the general symptoms of 
disease wjould depend on the quantity of destroyed ba- 
cilli and a larger or smaller resorption of toxins. 
Furthermore, the pathologists will w/onder what 
type of the toxic effect occurs in the intestine, name- 
ly whether there is a necrosis due to a chemical effect 
of the toxins, which means a direct effect, or whether 
there is another type of necrosis due to circulatory 
disorders. The microscopic examination alone is hither- 
to not able to decide this satisfactorily. The enormous 
congestion of the terminal vessels observed by DOPTER 
and others is remarkable indeed. This suggests that the toxin injuries the epithelial cells not only directly 
by invading them from the intestine or passing through 
them when it is secreted, but that a component damaging 
the vessels is also present, which either occurs simul- 
taneously with a damage of the epithelial cells, or pro- 
vokes it. To elucidate this experiments should be made 
which investigate the toxic effect of carefully charac- 
terized toxins on the capillaries. Personal experiments 
concerned with that matter are not finished yet. The 
histological investigation of early cases with damages 
about to appear should be pushed on as much as possible, 
since the morphologic observations seem to suggest that 
a vascular impairment is an important component. This 
is particularly obvious with early oases which show a 
very considerable hyperemia of the smallest and medium- 
sized vessels. In the histologic picture attention is 
frequently attracted by white and hyaline thrombi in 
the capillaries, which are enormously filled. I have 
the impression that the epithelial cells and glands are 
only secondarily involved when the mucous membrane is 
impaired; for, with early cases they are not yet altered, 
even when the cellular and fibrous interstitium was im- 
paired by a stasis, hemorrhages, and a fibroid necrosis. 
At any rate, it is sure that the impairment does not 
origin from the epithelial glands, but from the inter- 
stitium and the vessels. Another question may be what 
the extent of the inflammatory and of the circulating 
components of the rather considerable submucous edema 
is. This too, can only be cleared up by a very fresh 
and properly hardened material, which should be re- 
membered during future autopsies. 
Discussion: 
GUTZEIT; Mr. LETTSRER believes for theoretical 
reasons that dysentery can be prevented by immunization. 
The recently introduced prophylactic dysentery immuni- 
zation will show whether this is possible. To evaluate 
the result of this vaccination the following measures 
are necessary; 
1. To make a note in the soldiers* pay-books as 
to the type and dose of the vaccine used - 4 different 
vaccines are available - and of the date of the vaccin- 
ation. 
2. To keep accurate statistics in all army groups 
in which the immunization was carried through, on 
number of dysentery cases and the cases of diarrhoea in 
relation to the actual number of men. 
If this will be done, one doubtlessly will be 'able 
to draw conclusions on the effectiveness of the various 
vaccines and to prepare the most efficient of them for 
future times after the following dysentery epidemic. 
The great number of chronic intestinal diseases ob- 
served during the winter, which resulted in a consider- 
able general weakness of the patients, and which some- times is caused by a chronic dysentery and sometimes by 
post-dysenteric intestinal injuries, makes it necessary 
to cure the cases of summer dysentery thoroughly and not 
to discharge these patients to their units as fit for 
duty too early. If these hints are sufficiently observed, 
post dysenteric intestinal injuries are avoided. Moreover, 
HCl-pepsin not infrequently has a rapid effect on such a 
chronic disease, since this is often accompanied by an 
anaoidity of the gastric juice. 
It is important to know that comparative investi- 
gations of the treatment of dysentery by HOLLER during 
the last Flexner epidemic revealed distinctly that in 
oases of a fresh dysentery a massive therapy (6, 5, 4, 
3, 2,1 gnu in daily decreasing doses) with Eubasin was 
superior to the special diet and heat therapy as well 
as to the phage therapy. However, the dose of this drug 
must be high enough. 3 times 1.0 gm. per day are apparent- 
ly not sufficient. The results of HOLLER are statistic- 
ally proved. Approximately the same favorable effects 
may be expected from serum therapy which should always 
be employed, when there is a serious pyrexia. BILLIEG 
reports that the sulfonamides, also have effects upon 
the contact carriers of dysentery. Instead of Eubasin, 
which sometimes causes disorders of the stomach, an e- 
quivalent dose of Eleudron may be given. 
WALTHER: Bacteriological investigations revealed^ 
a distinct effect of the sulfathiazoles and sulfapyridins 
on the gram-negative bacteria, particularly on the dy- 
sentery bacilli. This shows that it is advisable to use 
these preparations for the treatment of the bacillary 
dysentory. 
VOIT: A large dose of Eubasin (6gm.pro die) some- 
time s"HacT”t he favorable result that the hemorrhagic 
diarrhoea disappeared earlier than without this drug. 
The greatest emphasis should include an extensive 
supervision of the lavoratories and one must particularly 
insist on covering of the faeces with earth. 
HOLM stresses the importance of an individual heat 
protection device (abdominal protector). 
KAXIFEMANN: One cannot warn enough from taking cold 
drinks* It occurs rather frequently that toxic symptoms 
of an adrenal deficiency occur which are easily checked 
by Cortiron., 
SCHRSIBER: The use of dysentery phages during war-, 
time is not advisable from the military point of view. 
The issue of phages is only allow?ed to the Special Group 
for Epidemic Diseases of the High Command of the Army. 
WOHLFEIL gives his differing views on the percen- 
tage of the "components of the dysentery vaccine. He makes 
the following statement: 
1, There is no Shiga dysentery at all in the cen- 
tral parts of the Eastern Front. Only the Flexner dysen- tory is usual there. 
2. An inhibition of H. SCHMIDTfs (Marburg) anti- 
genic effect must bo expected when Shiga bacilli and 
cultures poor in dysenteric micro-organisms are given 
together. 
3. For the purpose of therapy only monovalent 
anti-dysenteric sera should bo made available in the 
Medical Supply Units. 
BIDLING confirms the 1st statement and says that 
in the region of his Army Group too the Floxner dysen- 
tery appeared exclusively. The loss they have been sub- 
jected to a procedure of purgation the more the endo- 
toxins act as antigens. 
RODENWALD replies to the question with his ex- 
peri enciTTxFlHTo continuity of the protection of Mecca 
pilgrims and the Dutch Amy in Insulinde, which was vacci- 
nated against Shiga for 1? years by the Otton vaccine. R. 
is of opinion that the protection lasts for at least half 
a year. The value of this typo of vaccination depends on 
its results. 
MUGROWSKI states that according to his investigations 
Shiga dysentery seems to occur only in Southern Russia. How- 
ever, this may change again. The dysentery immunization of 
12 400 prisoners in concentration camps revealed the ab- 
solute inefficiency of the adsorbate vaccine manufactured 
by the Behring works, while Dysbakta was very effective in 
11 000 persons and the vaccine of the Saxon Serum Works 
on 8 000 persons, as also the Dysperos on 4 000 persons. 
However, the evaluation was only based on the outcome of 
whether a camp epidemic was stopped or continued. The Asid 
vaccine was not investigated. Phages (Behring 'Works) given 
three times as a dose of 10 cc. 14 days were very 
successful with 12 000 persons. 
GLAUBER: Refers to the principal results of the 
numerous investigations of the problem of the active dysen- 
tery immunization made in the Institute for General and 
Military Hygiene of the Military Academy. Various old, 
new, and the latest vaccines were tested by examining the 
serum of man for anti-octo- and anti-ondo-toxins. The 
results were: 
1. There is no final and incontestable solution yet 
of the problem of "active dysentery immunization", although 
a considerable improvement was accomplished in the last 
years, so that it seems to be justified to practice it 
at the present time. 
2. The adsorbate vaccines which were particularly 
recommended during the last years proved no more ad- 
vantageous than the formol vaccines. However, one must 
take into account that the efficiency of the latter is 
reduced during storage. The assumption of PRIGGE, which 
was repeatedly confirmed by experiments, namely that the formalin doos not metamorphose the Shiga-ectotoxin into 
a toxoid, but that it destroys it in the course of time 
increasingly until it has become completely useless was 
supported by the tests. Even the effect of the endo- 
toxins was reduced later on, so that investigations must 
be made of whether the formalin reduces the antigenic 
functions of the dysentery endotoxin. This question may 
be of some importance because it could be proved that the 
admixture of formalin was demonstrable for several months. 
This shows that the formalin is decomposed only very slow- 
ly. Therefore, the formol vaccines can bo kept on storage 
for a limited period of time only. Further tests are to 
show whether the formalin can be bound by suitable che- 
micals without any impairment of the vaccine aft or if has 
served its purpose. 
3. The results of the immunization may be improved 
when vitamin G is given to vaccinated persons suffering 
from a deficient vitamin G supply. Therefore, attention 
has to be paid to provide enough vitamin C when the food 
is poor in vitamins. 
4. In the combined vaccines against dysentery and 
tetanus the dysentery antigen was reduced in favor of the 
tetanus antigen, so that the greatest caution is required 
when combined vaccines are used for the immunization a- 
gainst dysentery. 
VIEHTHALER: For the time being the formol vaccine is 
the only vaccine available. If one attributes a great im- 
portance to the concurrence of antigens, any immunization 
with a polyvalent vaccine is impracticable• 
KOCH: The marked submucous edema is conspicuous. 
Like the circulatory disorders it is probably of a toxic 
origin. 
S3EGMUND; According to my investigations the alter- 
ations of the mucosa during dysentery are initiated by 
circulatory and vascular alterations which include an 
ordinary peristatic hyperemia with a plasma diapedesis 
as well as a complete stasis with a corresponding impair- 
ment of the tissues cand the epithelium. I am of ( pinion 
that the general cause of these disorders is an altered 
permeability of the mucoufe epithelium for the toxins re- 
leasing the vascular changes. I made reference to the 
relation of dysentery to the serous inflnmm tion during 
a lecture held in a conference of consulting specialists. 
CLAUBSRG; as to the formol dysentery vaccines I want 
to make reference to what 1 stated above and to under- 
lino that these vaccines are not sufficiently tested yet, 
and that no final opinion can bo given on them. Par- 
ticularly the period during which they are employable 
should exactly be determined. We have observed that old 
vaccines may become valueless. Failures of the immuni- 
zation against the dysentery with formol preparations, 
therefore, should not be attributed to the procedure as 
such. Furthermore tho problem of the dysentery bacillus 
carriers has boen repeatedly discussed in recent tines. 
Previous observations by which it was shown that in 
regions where dysentery occurs as an endemic infection, 
the dysentery bacillus carriers may bo the rule and the 
disease itself an exception, were frequently confirmed. 
Thus it needs no particular explanation that under cer- 
tain conditions an epidemic of dysentery breaks out with- 
in a latently infected unit, when the physical resistance 
of the men is reduced by climatic conditions, inappro- 
priate food, unusual exertion, etc. Such an epidemic may 
show any clinical symptoms, from a harmless enteritis of 
short duration to a most severe fatal disease with tho 
symptoms of cholera, according to tho disposition of tho 
patients. This knowledge prevents us from accepting the 
much discussed erroneous and dangerous hypothesis that 
under certain conditions the common intestinal bacilli 
are transformed into dysenteric bacilli. 
As to the repeatedly discussed close connection bet- 
ween dysentery and a hot climate, I should like to men- 
tion that besides the wellknown causes of the chrono- 
1 ogical coincidence of dysentery epidemics and high 
temperatures during summertime, functional disorders of 
the gastro-intestinal secretion play a part. According 
to recent studies a diminution or even a cessation of 
the gastric secretion nay occur during high external 
temperatures, /in ordinary acid gastric juice destroys 
the dysentery bacilli within 15 to 20 minutes. Hence, it 
takes part in the physiological defense measures against 
an infection. If a secreted amount of the gastric^juice 
is diminished or if there is a complete achlorhydria, its 
protective action must also be reduced or must cease en- 
tirely. Therefore, one should attempt to prevent this 
possibility by administering acid drinks during heat 
waves. 
Moreover, the importance of the fliv;S for the con- 
tamination with dysentery was This Is still 
more important'as tests of ROSE and co-workers became 
known recentlyi according to which in audition to^tho 
danger of an ordinary passive bacillary contamination 
through tho adhesive lobules of the fly logs the follow- 
ing mode of infection is possible; The uysentery bacil- 
li take over the task of the symbionts required for the 
development of the fly larvae. The bacilli are enclosed 
by the larvae, where they remain during the pupa^stage. 
Then they reappear with the excretions of tho flies. Directions for Measures against Dysentery. 
I. Prophylaxis. 
a) General hygienic 1a1v3QSLil*GS I 
1) Lavatory hygiene: If possible build 
covered lavatories and fill then up with earth 
before leaving the camp. 
2) Remove the slaughtering and Kitchen gar- 
bage. Keep the garbage dumps covered. 
No effective prophylaxis against the flies which 
play such an important part in the distribution of 
dysentery is possible if those measures are not 
carried through carefully. 
b) Personal prophylaxis. 
1) Drinking unboileci water should be forbidden. 
Cold drinks must be avoided. The flasks should bo 
filled with coffee every morning. 
2) If possible a protection against cold and 
wet should be provided. Building of tents. At 
night abdominal protectors should be worn. 
3) With the frequent appearance of intestinal 
diseases food poor of fat but rich in carbohydrates 
should be issued. 
U) A general immunization against dysentery was 
ordered. The following vaccines will be' used: 
1. The polyvalent vaccine of the Hygienic Institute 
of the University of Berlin. 2. The polyvalent vac- 
cine of the Behring Werke, 3* Aldystox. 4* The Shiga 
vaccine according to Otten (together with Dysperos). 
The pay-book and on admission to a hospital the me- 
dical history must contain a note as to which of the 
four vaccines mentioned was used. 
II. Treatment. 
Ij No long-distance evacuation. Experience has shown 
that the lives of many severe oases depended on the 
observation of this rule. 
2) Therefore dysentery hospitals should be estab- 
lished as close to the frontline as possible. Further- 
more, special wards for dysentery cases and those 
suspected of dysentery should be organized in all 
casualty reception stations, casualty clearing sta- 
tions, and hospitals. 
3) To relieve the hospitals convalescent homes for 
dysentery patients should be set up* and units be 
formed of such patients. No discharge to the units unless the general condition is good and the ordi- 
nary diet is well tolerated. No discharge of dysen- 
tery convalescents from their Army Group. 
A* The treatment of dysentery patients with heat, 
an appropriate management and a special diet are of 
a greater importance than the administration of 
Medicines. 
5* Castor oil should be given at an early time and 
to start the treatment, but not over a long period* 
Mild laxatives such as Epsom salts may be given over 
a prolonged period. No opium must be given in the 
beginning of the disease nor should it continuously 
be employed in the course of the dysentery, 
6. In severe cases an early treatment with dysentery 
serum is advisable, 
7, The use of sulfonamides (Eubasinum or Eleudron which 
causes fewer disorders of the stomach) has an 
encouraging but not conclusive experience. When em- 
ploying them comparatively large doses should bo ad- 
ministered w ithin a short period cf • time $ on the 1st 
day 6 gm., 2nd day 5 gm., 3rd day 4 gm. and so on. 
The total dose should not exceed 20-30 gms. When 
the stomach refuses them, no oral administration is 
possible, 
8, In cases of desiccation sodium chloride or tuto- 
fusin should be injected. Moreover, sodium chloride 
should be given per os in addition to hot drinks, so 
that the fluid can be retained in the tissues. 
9. Under certain conditions a solution of 10 c/o sodium 
chloride (20-40 cc.) may bo injected intravenously. 
A blood transfusion may be useful. 
10. The heart and the blood circulation must bo watched 
carefully. If a cardiac failure is Imminent, stro- 
phantin must be administered, 
11, During the after-treatment hydrochloric acid is 
appropriate in cases of gastric disorders which are 
frequently duo to an achlorhydria. If a chronic dysen- 
tery is accompanied by cachexia, a blood transfusion 
is advisable. 
b) Amebic Dysentery. 
Oberfoldarzt (Lt.Col. 10) Prof. RODENWALDT, 
As long as one knows the protozoa occurring as para- 
sites in the cavities of the body the discussion of their 
etiological significance as pathological micro-organisms 
has not come to an end. It is well known that studies 
are repeatedly published in which, in want of a better 99 
explanation, the thesis was set up that the lambliae and 
trichmondds were the causative gorms of the colitis, vagi- 
nitis, etc., because great masses of flagollatae were found 
in the stools or in the vaginal mucus. But other studies 
are published too, which refuse just as frequently the o- 
tiological significance of the flagollatae, and one must 
say that the knowledge of the matter is no bettor today than it 
was 30 years ago, when stress was laid upon the fact that 
no clear evidence of the pathogenesis was available, and 
that one was only able to' state that the flagellates en- 
hance in the one or the other way the growing patho- 
Ipgical processes. through the great number in whicli they appear, 
mtrthere 3s no decisive proof of such a thesis. The sta-. 
tistical evaluation has also failed. 
Among these protozoa the amobao received particular 
attention from the beginning. This may not be justified, 
sine e it certainly is no usual idea that the amebae arc al- 
so flagollatae which lost their organs of propulsion by 
their living as parasites. There are even amebae which 
under certain disadvantageous conditions form flagellao. 
But otherwise the resemblance is evident. In a certain 
environment the trichomonads are also able to move away 
by their psoudopodia. The cell structure shows no funda- 
mental difference. 
The problem of which ontameba causes amebic dysentery 
became less complicated soon after its discovery about 50 
years ago. It was discovered rather early that large ent - 
ameba coli having a uniform plasma and forming cysts with 
eight nuclei practically never contain any erythrocytes 
and are not pathogenic. 
Since SCHAUDINN’s studies nobody was over really in 
doubt that the entameba histolytica causes amebic dysen- 
tery. They contain erythrocytes even in cases of an acute 
dysentery and were found on the bottoiii of the intestinal 
ulcers of fresh and chronic cases of tropical eysentery 
and in the pus of the liver abscesses. 
Before 1912 it was almost a dogma that all dysentery 
cases occurring in the tropics wore amebic dysenteries, 
while all dysentery cases occurring in'the temperate zones 
were bacillary dysenteries. In the present time this is 
recognized as a big mistake. 
But it was always doubtful how the findings in the 
fresh specimens of the stools should bo interpreted. It 
was a great surprise when in the course of World^War I 
amebae were found during the examination of soldiers who 
returned from hot countries and previously had never 
suffered from dysentery at all. When the indigenous 
population was examined subsequently it was repeatedly 
confirmed that a high percentage of the population of 
the temperate zones were also amebae carriers (in our 
zone 1/4Pjo) who had never suffered from dysentery previous- 
ly, nor fell sick later. It is true that no erythrocytes 
were observed in these entamebae, but as to their shape, 
their motility, and their structure they resembled the 
ontameba histolytica closely. Their cysts having four 100 
nuclei, had the same shape as was heretofore described 
for the cysts of the entameba histolytica. 
Concerning this observation I want to mention that 
the recent research work has disclosed that the entameba 
histolytica occurs in man in two forms: As the tissue- 
invading form, which is the ent. hist, in the proper sense, 
and as a form which is present in the intestinal lumen, 
the precystic form of the ent. hist. This is a saprophytic, 
and inoffensive intestinal parasite. The most important 
factor, however, is that the pathogenic stage of the ent. 
hist., which is the tissue-invading form, never forms cysts. 
These are exclusively produced by the precystic form. From 
this the important conclusion must be drawn at first that 
it is not permissible to diagnose amebic dysentery from the 
presence of cysts exclusively as frequently occurs even at 
the present time. This would be a mistake even if the 
patients had suffered from dysentery previously, since this 
might have been of another origin. 
The only reliable conclusion to be drawn from the 
presence of cysts is that the carriers of the precystic 
forms are liable to an amebic dysentery. The modern the- 
sis is that the precystic form may, but by no means must 
be transformed into the histolytic form, that means the 
tissue-invading form, as soon as a possibility is given 
by some injurious even to invade the tissue of the intes- 
tinal wall through a locus minoris resistentiae. This 
happens more frequently in hot countries and at certain 
seasons than in temperate zones. Therefore, it is a dis- 
ease occurring in hot countries. But infections with the 
amebic dysentery may occur even in our climate, and it is 
a well known fact that an amebic dysentery contracted in 
hot countries may continue in our zones. Without drawing 
far reaching conclusions I want to refer to the fact that 
this thesis is not yet incontestable. It is well known 
that cats can be contaminated per anum with the entameba 
histolytica and the anatomical signs of a real amebic dy- 
sentery be provoked. But WESTPHAL found that itis possible 
to provoke exactly the same symptoms with cats, if one first 
filters the stools of a sick cat used for the contamination 
and employs this filtrate which is free of amebae to con- 
taminate another cat. Such an observation calls forth some 
scepticism and it suggests that another micro-organism, 
probably a virus, might possibly be involved as well, and 
that the occurrence of amebae transformed into tissue-in- 
vading forms is-only a secondary event. The method of how 
the amebae destroy the tissues, whether directly or by an 
enzymatic effect is also not yet incontestably known. But 
these interesting studies are of no practical significance, 
since the entameba histolytica remains at any rate the most 
important indicator of that specific intestinal 
which is called amebic dysentery, and also of its complica- 
tion, the liver abscess. 
A proof of the diagnosis of amebic dysentery in ad- 
dition to several clinical symptoms is the presence of 
the tissue-invading forms in the fresh specimens or the 
stained preparations, that means of a creeping entameba 
putting out its pseudopodia, and a distinct difference 
between its endo- and ectoplasms. Many amebae in acute cases almost all of them enclose erythrocytes in their 
gelatinuous mucus which contains few leukocytes. 
Here, I make no detailed reference to the clinical 
findings which must also be critically considered, since 
it is very difficult to evaluate correctly the findings 
in the native preparation, A considerable experience 
is required for this. The microscopical examination of 
the stools with regard to amebae is a most difficult task. 
The clinical signs which permit the diagnosis are the 
proctoscopic proof of typical rectal uloern, which also 
permit the retrospective diagnosis of a liver abscess 
as due to an amebic dysentery. However, it is certain 
that the dysentery of a bacillary origin and intestinal 
diseases of another etiology are much more frequent than 
amebic dysentery. The presence of precystio and cystic 
forms does not permit the diagnosis of an amebic dysen- 
tery. This can only bo made sure when tissue-invading 
forms are found. 
From the epidemiological point of view one must state 
that the carriers of precystlc forms are more liable to 
fall sick with amebic dysentery when a locus minoris re- 
si stentiae is developed than persons who era free from 
them. But there is no reason to believe that such people 
necessarily contract an amebic dysentery when they come 
into the tropics as was recently stated. If this would 
be the case about 14 % of all Europeans going to the 
tropics would fall ill with amebic dysentery. In the 
populous towns of the Dutch Indies wLero there is a con- 
tinuous coming and going of Europeans, no such findings 
are known. Despite the fact that the percentage of 
Europeans becoming carriers of the intestinal forms 
is much greater in the tropics than in Europe, the amebic 
dysentery has become very rare in tropical cities with 
comparatively satisfactory hygienic conditions under the 
conditions of peace. Since Yatren and Riboflavin-have been 
used the liver abscesses have almost disappeared. War 
changes these conditions. Then the intestinal disorders 
become more plentiful and the possibilities of a metamor- 
phosis of the intestinal forms into tissue-invading forms 
become more frequent* To reduce these possibilities by 
providing an adequate diet, by combatting bacillary dysen- 
tery and other intestinal diseases, by providing an en- 
tirely safe water supply and the best possible garbage 
and sewage disposal system, is the most essential base 
for any defense against amebic dysentery during war time. 
The result of the present tests will show whether the 
prophylactic administration of Yatren or Riboflavin will 
be helpful in controlling amebic dysentery. But there is 
no help against a certain percentage of people becoming 
carriers of precystic forms in hot countries and carrying 
these forms with them. The same applies to the gradual 
and steady increase of their number. To chock the 
tribution of amebic dysentery by segregating those carriers 
in\the homeland or by curing them, or by examining them 
when arriving in the operational areas and sending them 
back, is not practicable. Such a suggestion is compatible 
neither with an epidemiological nor with military reason- 
ing. 102 
Discussion: 
HAUER: I should like to discuss from tho viewpoint 
of clinical medicine Some points which seen to me of a 
particular importance for tho medical officers of the 
units as well as for the practitioners. Two of them may 
bo particularly underlined; these are; 
1) As impossible as it is not to notice the 
fully developed symptoms of amebic dysentery with its 
triad of gastric pains, a diarrhea with an evacuation 
of a hemorrhagic gelatinous mucus, and continuous te- 
nesmus, it is equally easy to overlook the atypical 
course of acute and chronic amebic dysentery. The former 
is sometimes hidden behind a common diarrhea while the 
latter is accompanied by frequently atypical symptoms 
such as gastrc-intestinal disorders, nervousness, pains, 
particularly of the loft hypochondriac region, and by 
a loss of weight. Quite a number of of amebic 
dysentery occur and then are present for many years 
without the slightest disorders of the digestive func- 
tion of tho gastro-intestinal tract. It is, therefore, 
desirable that evjry soldier reporting sick and pre- 
viously or recently living in warmer climatic regions 
be immediately examined for entaaebic histolyticae. 
( 
2) More than that the attention of tho pr pe- 
titioners and of the medical specialists serving with 
the units must be directed to the liver abscess which 
is tho most misunderstood or overlooked tropical dis- 
ease. If any person who previously or recently had. 
spent a certain period of time in a country where ent- 
amebic histolyticae occur falls sick with pains in the 
right hypochondriac region, remittend fever, and marasmus, 
the possibility of a liver abscess must be borne in 
mind without regard to the fact whether the patient con- 
cerned suffered from dysentery at an earlier time or 
not. It should not happen again that a man falling 
sick with periodic febrile attacks nd hemorrhagic 
stools in the Balkans is admitted later to a hospital 
at home under the diagnosis of a typhoid fever and then 
dies from malaria because nobody took this disease in- 
to consideration and because no blood examinations were 
made at the right time. It should not happen either 
that a soldier who reported sick with diarrhea in Northern 
Africa dies in a hospital at home from an undiagnosed 
liver abscess. 
One particular case nay bo stressed: A 3$ year old 
corporal, who was never sick before, was transferred in 
May 1941 to North Africa with his unit and fell sick 
there with a severe diarrhea in June 1941* This diarrhea 
grew worse towards the end of the year and mucous hemorr- 
hagic stools were passed as frequently as 10 times daily. 
By the end of December an icterus appeared. The patient 
was transferred to a hospital at home. When he arrived 
his temperature was 3S.3°C., the pulse rate 118/min. The 
temperature curve showed high remissions. There wore no 
pronounced pains in the right shoulder or in the hepatic 103 
region. Precystic and cystic forms were found in the 
stools. A Tatren cure was made. The diagnosis of the 
surgical department was carcinoma of the rectum. As 
the condition of the patient deteriorated, he was trans- 
ferred to a surgical ward, where the surgical inter- 
vention was postponed to a later date. The amebic in- 
fection was preliminarily treated with Yatren. The con- 
dition of the patient continued to deteriorate, a severe 
collapse occurred and the patient died. The autopsy 
showed an extensive ulcerating colitis with multiple 
abscesses and perforations of the sigmoid. There was a 
suppurative peritonitis and several liver abscesses the 
size of an egg. One of them had ruptured into the 
thoracic cavity. 
In this case the patient would have been saved, if 
one had thought of the possibility of a liver abscess 
and adequately treated him with emetin. 
Patients who previously had not suffered from in- 
testinal disorders may also suddenly fall ill with a 
hepatic abscess. Two such cases will be re_orted here, 
one of them being that of a soldier who suffered from 
amebic dysentery many years ago in Eastern Africa,the 
other one being a member of the German Africa Force, 
who for the time being is under treatment in the Mili- 
tary Hospital # 118. 
The former was a 26 year old private who was a 
farmer's assistant in Africa from 1935-1939- There, he 
was repeatedly contaminated with malaria, the last time 
in 1937, but he had never noticed any signs of intes- 
tinal disorders. During the battle of France ho was sub- 
jected to great physical exertion and he fell suddenly 
ill with rigor, high pyrexia, pains in the right chest 
and a dark, hemorrhagic sputum. From the station hospital 
he was transferred to other hospitals with the diagnosis 
influenza, pneumonia, similar diseases, then malaria, 
sepsis and tuberculosis were suspected successively. 
Finally he was admitted to the Military Hospital § 118 
under the symptoms of a chronic malaria and a diaphrag- 
matic irritation. The margin of the liver was palpable 
and there was a considerable tenderness of the gall blad- 
der region. Previously the malaria was not considered 
as the cause of the symptoms, but rather a pneumococcal 
septicaemia and appropriate investigations were made. 
When a blood culture and all other examinations had a 
negative result, the suspicion arose that the symptoms 
might be due to a hepatic abscess. The inspection of 
the provoked stools revealed the presence of precystic 
and cystic forms of the entameba histolytica. The treat- 
ment consisted of the administration of ©netine and Yat- 
ren. From the first day of treatxaent on the persistent 
pains in the right hypochondriac region disappeared, and 
on the third day the remissions of the fever which were 
present for 93 days vanished entirely. The patient re- 
covered rapidly and his body weight was increased by 14 lb. 
The hemoglobin was restituted to 100 %• The patient was 
sent back to his unit and for a long time he has been 
fit for duty. A similar case is that of the 32 year old corporal 
Erich E. This soldier served with his unit during the 
battle of France and was then transferred to North Af- 
rica where he remained from March 1941 to March 1942. 
Previously he did not have any intestinal disorders. 
A temporary loss of weight was noticed by him during 
that period of time. On 4 April 1942 while on leave, 
he suddenly fell sick with a rigor, a high pyrexia 
(40.5°C.), a profuse sweating during the night. No 
pains were felt at the onset. He was admitted to the 
Station Hospital § 118 with the diagnosis of malaria. 
The thoracic organs showed nothing abnormal. The liver 
was not palpable. The blood count showed 12 000 leuko- 
cytes, the differential blood count 14 % band forms, 
46 % neutrophils, 33 % lymphocytes, 7 % monocytes. On 
the third day the patient was in a toxic condition. 
There was no tenderness of the liver, while there was 
a slight bronchial rasp and a dullness on the right 
thoracic region. The differential diagnosis was: Pneu- 
monia after an exudate,or liver abscess . A Eubasin 
course with 6 gnu was not successful. In the stool 
lambliae were found, but no amebae. From 12 May on, 
pains were continuously felt in the right chest. The 
liver was not palpable, but somewhat tender. No amebae 
were found in the stools. 
Urine: Urobilinogen + *, Deposit: hyaline and 
granulated casts. Pleural puncture: The pleural cavity 
seemed to contain no fluid. Subsequently a creamy 
yellowish pus was withdrawn. There were no protozoae 
in the aspirated fluid, but it contained bacilli and a 
few cocci. The patient was transferred to the surgical 
department of the Military Hospital jf 122, with the 
suggestion that there might be a liver abscess. A Buehlau 
drain was used and the diagnosis of liver abscess con- 
firmed. The temperature dropped slowly and the X-ray 
findings showed nothing abnormal in the lungs, but a 
typical elevation of the diaphragm at the right side. The 
patient was transferred back to the Military Hospital // 116 
again. Entamebae histolyticao were not found before the 
28th day of disease. Then vegetative and precystic forms 
as well as cysts were confirmed in the specimens. 
The cases of amebic dysentery admitted to the hos- 
pitals during this war were either old cases of previous 
infections in Africa, China, South America and other 
countries, or new cases of the disease which were ac- 
quired during the war in Southern Europe, North Africa 
or Russia. At first only old cases with a definite 
anamnesis of amebic dysentery were admitted to the Mili- 
tary Hospital # 118. The complaints were similar to those 
above. They were increased in severity or provoked by 
the service with the units. We were able to cure a number 
of such infections acquired in the past. However, quite 
a few of thess patients attributed their disorders to an 
amebic dysentery which actually was cured; here, another 
disease was usually active which, therefore, made us 
think of similar cases of post-war malaria. Amongst 
the admitted patients sent from the Russian front which 
were contaminated there, 1st Lt. C. was particularly of interest since he was the only patient with whom I 
noticed the usual collection of all the symptoms of 
amebic dysentery together. 
The North African entamebae histolyticae are of 
another type. Cases of amebic dysentery have occurred 
frequently since the middle of August 1941. From this 
time on 181 clinical cases have been observed. They 
usually had the same previous medical history: Frequent 
thin'stools which were accompanied by fever for several 
days, temporarily hemorrhagic stools, a considerable loss 
of weight, and a continuous or a periodical diarrhoea. 
However, these are vague and atypical symptoms. The 
disease is hidden behind the symptoms of an ordinary en- 
teritis. In the stools precystic or cystic forms are 
usually found, while tissue invading forms occur in- 
frequently. In cases of a demonstrable strain, but even 
without any obvious reason one sees that latent infec- 
tions become virulent,and dangerous complications are 
sometimes observed. Therefore, the North African typo 
of amebic dysentery has a particularly insidious cha- 
racter . 
I am of opinion that the question of whether these 
carriers of precystic and cystic forms in North Africa 
should be treated like amebic dysentery patients, ought 
to receive a positive answer, provided that the par- 
ticular conditions such as the climate, the diarrhoea, 
the unusual food, the phsyioal and other strains are 
considered. After our practical experience and obser- 
vations I do this as a principal. 
As to the diagnosis I want to mention that except 
for very obvious cases it is our custom to examine fresh 
specimens, specimens treated with Lugolfs solution, and 
stained specimens of the stools of all patients after 
provocative measures. The proctoscopy has been made as 
a routine measure for a long time. Here I am not in the 
position to give details on the treatment of amebic dysen- 
tery. Wo use Emetine and Yatren anyway; instead of the 
latter drug Enterovioform or small doses of Riboflavin 
are sometimes advisable. A Yatren enema.should be com- 
bined with the oral administration of that drug. An 
icterus occurring in addition to amebic dysentery may 
be due to a liver abscess. Consequently emetine should 
regularly be employed. Hydrochloric acid preparations 
are recommended as a routine treatment. We also used' 
the parenteral administration of liver preparations, 
while vitamins were given in exceptional cases only. 
In recent times we made an attempt with blsmuth-arsin- 
acid preparations with obviously favorable results. Annex 
The Disinfection of Raw Vegetables and Fruits in the 
Tropics* 
In the tropics the vegetables and the fruits are 
frequently contaminated with bacteria, amebic cysts and 
worm eggs by fertilization with human feces, by dust and 
flies, etc. As far as fruits with a skin are concerned, 
it is permissible to eat them, if they are peeled first. 
However, it must be insisted that they are peeled by the 
soldiers themselves and not by indigenous servants. Vege- 
tables , however, which are preparecTas salads, and fruits 
without a skin ( such as strawberries, etc.) should be 
cleaned and disinfected, if there is any possibility to do 
this. For this purpose the most’various suggestions wore 
made. 
VENDHAMINI (1939) sterilized strawberries by exposing 
them to a 1 jb hydrochloric acid solution for half an"hour. 
He reports that the taste of the strawberries is not im- 
paired by such a treatment,if they are washed immediately 
afterwards in clean water. VAN DEN BRANDED and GEEKS 
(1938) report that salad can be disinfected by washing 
it for 10 minutes in commercial vinegar and subsequent- 
ly cleaning in water. Numerous authors suggest the use 
of a potassium permanganate solution for the purpose of 
washing the vegetables. But they give almost no accurate 
data on the concentration-!)! the potassium permanganate 
solution to be used. Some of them request a pink, others 
a dark violet solution. GAUDUCHEAU (1937) cleans straw- 
berrios in the following manner; Tho dirt is removed in 
water; then the fruits are placed into a diluted potassium 
permanganate solution (1:2 000) for a quarter of an hour. 
Following this procedure one cleans the fruit three or 
four times with pure water and permits the water to drain 
off. The chemical effect of the permangnnte solution 
together with the mechanical effect of the cleansing was 
said to be sufficient to destroy or to remove all, or at 
least almost all bacteria, amebic cysts and ova. Con- 
trary to that BERNHARD (1937) states that saladDleaves 
mav be contaminated with goli bacteria and staphylococci 
even after an exposure to q rather concentrated potassium 
permanganate solution (57?,). In addition he stresses the 
fact that even after treatment with a solution of 0.1 % 
the salad is spoiled to such an extent that it cannot 
be offered for human consumption. 
The most detailed statements on the resistivity of 
tho cysts of the Entameba histolytica are found in a study 
of CRAIG and FAUST (1937). These authors stated that the 
cysts of the amebae remain alive in a diluted permanganate 
solution of 1:500 for a n of loci df~~21T'tQ RU hours, (in a ” 
humid ground the cysts allegedly are alive for more^than 
12 days, in water for 9 to 30 days.) Against chlorine 
they are also able to offer considerable resistance, for 
a hundred times that chlorine concentration is required to kill them, which is usually employed for the disinfection 
of drinking water. Ghloramine is still more ineffective 
than the pure chlorine. Even when exposed to strong 
poisons, such as a watery sublimate solution (l:2500) 
the amebic cysts remain alive for about 30 minutes. The 
same applies to the exposure to a o.5 % formalin solution. 
Some of the authors give priority to the disinfection 
of the fruits by exposing them to boiling water. This seems 
indeed to be the most certain method. The' suggestion is 
made in the text-book of HUGE, MUEHLENS and ZUR VERTH to 
expose the salad to boiling water for about 30 seconds. 
BRAUN (19291 is also of (pinion that heating the fruits 
in boiling water for 30 seconds or in water of 65°G for 
30 minutes is sufficient. 
Discussion: 
HABS recommends the use of potassium permanganate 
since hereby the cookhouse personnel are compelled to 
repeat the cleaning of the fruit. 
WINKLER reports that dysentery bacilli are destroyed 
if the salad is immersed in hot water for 10 - 15 seconds. 
RODENWALD: The problem of how to clean the fruit 
plays only a part during war and in X->eacotime has nothing 
to do with amobic dysentery and other diseases of the 
intestine. Therefore, in areas whore topdressing is 
practized the strictest orders have to be given. Eat only 
vegetables the source of which is known. Therefore, it 
is suggested that the units themselves should cultivate 
vegetables. 
Directions* 
Memorandum concerning Amebic Dysentery.* 
General Rules. 
Amebic dysentery is an infectious disease of the 
intestines, which is distributed throughout most of the 
tropical and subtropical countries. In the subtropics 
it particularly occurs during the hot summer months. 
From the intestines the infectious organisms may be 
carried via the blood to the liver and to other organs 
and may provoke abscesses there. 
The Infectious organism of the amebic dysentery is 
the Entamoeba histolytica, which is classified within the 
group of protozoae. It normally occurs in an inoffensive 
form in the lumen of the intestines, the so-called "Minuta"- 
form (precystic form, 12 to 15 p in size) in the lumen of 
the colon and the cecum, without causing symptoms of the 
disease. The carriers of this precystic form of the amoebae are healthy bat under certain conditions nay become 
dangerous to those near then. For, by a process of 
rounding off and by formation of a protecting nenbrane 
the permanent form, i. e•, the cysts originate, which 
remain alive in the open air in the excreta, in the 
sewage, and in the superficial layers of water pools. 
The healthy carriers of amoebae continuously excrete 
amoebae with the stools. In consequence the clinically 
healthy carriers of amoebae are sources of a spread of 
amoebae. Unnoticed and without knowing it themselves, 
they help to distribute the infection throughout the 
units. In tropical regions and under primitive unhy- 
gienic conditions a high percentage of men may become 
carriers of the amoebae causing dysentery. In Europe, 
too, a certain percentage of persons is infested by the 
precystic (J,Minutaf?-) form of the entamoeba histolytica 
which, however, in cool regions rarely causes dysentery. 
Infections take place when 
1. Hands, food, nd water are soiled, particularly if 
fruits, vegetables and raw vegetables are contamin- 
ated by excreta containing cysts. In countries 
where top-dressing is customary, salads made from 
vegetables should not be eaten. 
2. The most important source of infection are the flies. 
From the human feces the cysts, of the amoebae caus- 
ing dysentery are taken in by the flies and ex- 
creted without being injured. Hence, the cysts may 
be carried by the flies over a largo distance of 
space and time. Other vermin, (such as cookcroaches, 
rats) may also convey the cysts. 
The disease is released, that moans the amoebae in- 
vade the intestine wall, if "this is impaired by a transi- 
tory or persistent diminution of its resistance, such 
as bacterial or other injuries of tho colon, particularly 
by contamination with dysentery and bacteria which fre- 
quently occur in tropical regions. In the subtropics 
that invasion occurs predominantly during the hot seasons. 
The course of amoebic dysentery shows different 
f orms: 
1.) The genuine, pure amoebic dysentery, 3 to 11 
weeks after the unnoticed invasion of the amoebae into 
the colon walls (incubation period) an hemorrhagic, prac- 
tically leucocyte-free and therefore completely transparent 
pink-colored gelatinous mucus is discharged with or with- 
out feces from the colonic ulcers, which were formed in the 
meantime. In this mucus the t issue-mm vading~f orm of TheT" 
amoebae is found by microscopic examination, in most_cases 
containing ingested erythrocytes and showing tho typical 
creeping movements. In contrast to that the mucus of"the 
bacterial forms of dysentery has a milky or yellowish turbid 
appearance which is due to oho high leukocyte content. In 
most cases the development of a genuine dysentery goes a- 
hoad slowly by further distribution of tho colonic amoebic 109 
ulcors throughout the colon. As a rulo in the beginning 
no fovor occurs, but subsequent to the insidious onset 
of the disease drawing pains in the hepatic, or splonio 
flexuro of tho colon are felt, sometimes r'.lso in the iloo- 
coecal region. If the first attack of the disease is not 
cured the genuine amoebic dysentery adopts the 
tendency to a chronic course with relapses. In such 
cases there is always a danger of perforation sometimes 
even during the first seizure of disease. 
The feces of the patients suffering from amoebic 
dysentery, which contains exclusively tissue invading 
forms but no cysts, are not infectious in themselves. 
Therefore in most cases no real epidemics start in the. 
sense that the amoebic dysentery is spread from tho pa- 
tients as a source. 
In spite of this, above all in view of the occurrence 
of mixed infections the feces of persons suffering from or 
suspected of amoebic dysentery should for practical pur- 
poses be treated as if infectious material. 
2. ) The mixed amoebic dysentery; This is the basic 
disease which in most cases is" cansed by bacterial debris 
and amoebic dysentery associates with it. The mucus con- 
tains leukocytes and it is turbid. In most oases the 
disease sets in with fever and other toxic effects of the 
bacillary infection. In such cases dysenteric diarrhoea© 
immediately sets in. The incubation period of infection of 
the tissue with amoebae is considerably reduced, that moans 
that tissue-invading forms appear in the feces very soon. 
If during repeated skilled inspection only "Minuta" 
(preoystic) forms were exclusively found, the diagnosis 
amoebic dysentery is not permissible forthwith, oven if 
there are symptoms suggesting dysentery. Under certain 
conditions the mixed amoebic dysentery may rapidly take 
a fatal course for which, however, the amoebic dysentery 
is of minor importance. Tho symptoms of the disease are 
principally determined by the kind of the basic bacillary 
disease. But there is danger of perforation too. This 
disease is particularly liable to relapse when associated 
with colds, excessive intake of alcohol when inappropriate 
or contaminated food is eaten, with undernourishment, and 
other diseases. 
3. If it is not treated at tho right time, amoebic 
dysentery may become very chronic and may persist for de- 
cades as a chronic condition. It may be hidden 
latency, which continues over months or years, and behind an 
ostensible recovery or very insignificant symptoms. (Sen- 
sitive, weak intestine, occasional abdominal griping, 
particularly in the left part of the colon, alternating 
occurrence of constipation and diarrhoea, which is not of 
the dysentery type, nervousness, loss of weight, pale, 
unhealthy appearance). Occasionally, particularly after 
an inappropriate diet, after overexert ion, after return 
to a hot climate the symptoms of an acute rolajjse with 
blood and mucus in the stools may reappear. 110 
The presence of chronic ulcers nay be the cause of 
a local peritoneal irritation and even of the formtion 
of abscesses; In such cases one has to abstain from 
a premature surgical intervention and at first start 
therapy by drugs with observation of the blood count. 
For distinguishing chronic amoebic dysentery from 
the chronic form of bacillary dysentery with which it nay 
have ccanon symptoms, in all cases of chronic dysentery 
a repeated bacteriological and serological examination 
is required. 
4*) Mostly in the course of chronic amoebic dysen- 
tery, sometimes, however, in the course of an acute amoe- 
bic dysentery and even, if at first there were no clinic- 
al symptoms of an amoebic dysentery, tissue-invading forms 
of dysentery amoebae may be carried from the intestines 
to tho liver and other organs, A hepatitis or an hepatic 
abscess are the most dangerous sequelae of an infection 
by amoebae. If such a complication is suspected endea- 
vors must be made to transport the patients to a hospital 
whore they must be admitted. The principal signs are; 
Irregular fever, frequently accompanied by rigors and 
profuse sweating, disorders of digestion, bronchial irri- 
tation and a dry cough, enlarged liver and tenderness of 
tho inferior hepatic margin, pains which frequently radiate 
to tho right shoulder, above all, however, an increase of 
the number of leukocytes (12 000 to 30 000 and more) and 
shift to tho left. If the abscess is encapsulated the 
augmentation of the leukocytes may be small. In the stools 
dysenteric amoebae are present. With solid stools 'the 
mlmata (precystio) form and cysts may be proven after 
provocation {Karlsbad salts). Patients with abscesses 
which have developed a longer time ago frequently bend 
the body to the right side when they are walking, support- 
ing the congested and painful liver with the right elbow 
and the left fore-arm. Tho face and tho conjunctiva© 
show a subicterio discoloration. Larger abscesses of 
tho liver may burst into tho lungs or to the outside, 
Tho occurrence of primary pulmonary abscesses is rare. 
Abscesses of the brain, tho sploon, or other organs aro 
very rare. 
II. Microscopical Piagnosis. 
In view of the great number of clinical possibilities 
(enteritis, bacillary dysentery, amebic dysentery) mic- 
roscopical evidence of parasites is absolutely necessary. 
This requires a special training to avoid an erroneous 
diagnosis. It is necessary to investigate the aysontoric 
stools or a fresh unstained specimen of material with- 
drawn by means of a proctoscope. 
Only fresh stools which, if possible? are not older 
than one hour should be examined. Thoro is no sense in’"in- 
vestigating specimen which have boon sent in over a long 
distance. The specimens (mucus or feces) arc smoarod'on 
a slide by means of a lancet or a platinum hook and dis- 
tributed with a physiological sodium chloride solution, if 
necessary. Attention must bo paid to take neither too small, nor too large a quantity of material. Cover it with 
a cover slip. The most appropriate magnification is the 
oil immersion and an ocular § 6. The shutter of the mi- 
croscope must be sufficiently closed. Tho diagnosis is 
made sure by the occurrence of the typical pseudopodia of 
the entamebae histolyticae looking like a hernial sac and.' 
being most conspicuous, if prepared at body 
and by phagocytlzed erythrocytes in the cellular, plasma 
of1 that"microorganism/ THe nucleus of the entamebae 
hlstloyticae is usually not visible in a fresh specimen. 
Attention must be paid to the number of leukocytes present 
in the mucus. If there is a genuine amebic dysentery, 
they are either entirely absent or present only in a snail 
number. The treatment with Lugols* solution ( k cjo iodine) 
kills the entamebae and stains them. In this case the 
nucleus is demonstrable as a ring usually with a. central 
enclosure, Tho principal source of errors is that leuko- 
cytes and other cells originating from the human organism 
arc mistaken for entamebae or the cystic forms of the ' 
amebae. Ihe diagnosis "necrobiotic amebae" is faulty 
in almost all cases. In doubtful slides the nucleus and 
the nuclear structure should regularly bo examined in the 
iodine preparation of the specimens. 
In vague cases and in chronic cases the diagnosis 
is made easier, if thin stools are provoked by the ad- 
ministration of Epsom salts or magnesium sulfate{1 to 
2 table spoons in one glass of warm water in the morning 
while the stomach is empty.J. 
An admixture of urine to the stools disfigures the 
microscopical picture of the entamebae histolyticae. 
III. Treatment of Amebic Dysentery. 
1. General management: The patients must immediately 
be put to bed, and, if possible, admitted to a hospital. 
However, a difficult evacuation and over a long distance 
should be avoided (danger of perforation). The bowels 
should be thoroughly opened by 20 to 30 gm. of caster 
oil or 0.2 to 0.3 gm. of calomel. The abdomen should 
be warned (abdominal protector or radiant heat). In 
difficult cases a hunger euro for three days should be 
attempted and only tea without sugar, rice water and 
oats boiled in water should be allowed. After a success- 
ful specific treatment (see below) a nourishing diet rich 
in protein is advisable such as milk rice, clear soup 
with the youlk of an egg, minced tender meat, mashed 
potatoes, semolina, fish, eggs with red wine, scrambled 
eggs, cream cheese, tender vegetables, bananas, minced 
apples, various nutrients, roborants, calcium-iron- liver 
preparations. During the second week an ordinary diet 
should gradually be administered, although fat, heavy and 
fermenting food such as legumes, corn bread and cabbage 
should be forbidden to the p tients. The gastric juice 
very frequently contains no hydro-chloric acid; sometimes 
a complete achylia occurs. In these cases pepsin hydro- chlrdc acid preparations should be given. The sodium 
chloride desire of the patients should be satisfied. 
2. Treatment with drugs. Two different ways of 
treatment must be distinguished: 
1. The intramuscular or intravenous injection 
of 0.03 or 0.05 gn# emetine twice daily, but not more than 
a total dose of i*0 gn., that moans a period of treat- 
ment extended over 10 days at the maximum. The treatment 
may be repeated after an interval of 8-10 days. Erne tin 
has only an effect on the amobae in the tissues (intes- 
tinal ulcers, abscesses). Hence, it effects only a clinic- 
al but no bacteriological restitution, (amobae carriers)• 
The intravenous application of emetine is preferable ef- 
fected through a syringe after adding 10 cc. of a 10 or 
20 % dextrose solution. If nausea, vomiting, or neuro- 
muscular weakness are observed the treatment has to be 
interrupted for a couple of days. 
2. Treatment through the intestinal surface. 
Drugs which come into effect in the intestines are: 
Yatren, Riboflavin, Spirocid, Enteroform, Bismuth. 
A careful oral administration of these drugs results in 
an elimination of the amebae present in the intestinal 
lumen and the intestinal ulcers are cured by their pene- 
trating effect. 
Yatren pills (0.25 gm.) three times daily or less, 
2-3 pills after eating, on the whole 80 to 100 pills 
during one course. If a severe diarrhea occurs the single 
doses should be reduced or the Yatren not given for 2 or 
3 days. In such cases it is advisable to administer the 
Yatren and small riboflavin tablets or spirocid simultaneous- 
ly* 
2 Riboflavin tablets (Rivanoletten) (0,25 gm.) may be 
given 3 to 4 times daily for one week. 
Spirocid: 2 tablets daily for 10 days. 
An incurable and old chronic diarrhea (colitis) is 
preferable treated with enemas in addition to the oral 
therapy, the colon is thoroughly cleaned by high enemas. 
After 1 or 2 hours, preferably in the evening, 200 to' 
600 cc. of a 0.5 % Yatren solution (or a Riboflavin so- 
lution 1 : 10 000 to 1 : 50 000) at body temperature should 
be injected. If necessary 10 to 20 drops of opium tincture 
should be added so that the enema remains in the colon for 
about 20 to 24 hours. The daily volume of the injection 
fluid should gradually be increased with each day. 
The permissible total dose of Yatren should not be exceed- 
ed, if it is given orally and rectally at the same time. The 
patients should be laid down in such a manner that the enema 
is retained for at least 8 to 12 hours. If this is not the 
case, the enema must be repeated. 
It is useful to treat a clinically and microscopically 
diagnosed amebic dysentery (with tissue-invading forms) with emetine and with a simultaneous rectal administration of 
drugs, to prevent subsequent complications, particularly 
liver abscesses* 
One week after the treatment is accomplished, to 
prevent a relapse, the stools ought to be repeatedly ex- 
amined and search must be made for vegetative and cystic 
forms of the entameba histolytica. 
If there are any signs of hepatitis or of a liver 
abscess the treatment with emetin should be confcinued 
until the symptoms have disappeared. 
The fully developed liver abscess needs surgical 
intervention. 
IV. Preventive Measures. 
A continuous instruction of the soldiers is the princi- 
pal measure. 
A.) It is desirable to avoid any contamination with the 
cysts of the entameba histolytica and any infection with 
bacteria promoting the outbreak of the amebic dysentery. 
1. It is required to build suitable lavatories 
where flies can gain no access. If this is not possible, 
the excreta must be covered with earth (spade method). 
2. The flies must be kept away by building lava- 
tories protected against the flies and by clearing the 
camps from food remnants, garbage, etc. (see leaflet: 
Fly Protection HDY 209 # XXI). 
3. Care should be taken that all foodstuff is stored 
in such a way that no flies gain access to it.. Food must not 
be left uncovered on tables. 
4. Orders should be issued forbidding the drinking 
of unboiled water, which has not been filtered through a 
filtering apparatus immediately above, even if this water 
is supplied in water cans. 
The water cans have to be disinfected at least 
once a month according to the orders of the medical 
officer of the unit. This is done by dissolving completely 
20 water disinfecting tablets in about 1 liter of water. 
This solution is immediately placed in the water can which 
is then filled up with water. The disinfecting solution 
should be left there for half an hour. 
5. Attention must be paid when the dinner pails 
are cleaned. Facilities should bo provided as much as 
possible to wash them with hot water. 
6. Fruits and vegetables must be carefully cleaned 
in boiled water. Fruits should be peeled after that pro- 
cedure. Fruits which cannot be peeled, vegetables, and 114 
salad which are eaten without being boiled have to be 
disinfected. The only procedure which was hitherto 
recognized as efficient is to dip the fruits and the 
vegetables into boiling water for 30 seconds. The 
chlorine taste is removed by washing them with boiled 
water. No iced drinks. Cookhouse personnel must be 
examined from time to time .as to their being contact 
carriers of the entameba histolytica. 
7. A close social intercourse between the sol- 
diers and the indigenous population which increases the 
number of possibilities of contact infections should be 
prevented. If it is impossible to avoid contact with 
the indigenous people, the hands should be washed after- 
wards. 
B. Warning against swimming in stagnant water or 
rivers. Sea bathing is permissible. 
9. The soldiers have to be ordered to report any 
excretion of mucus or blood with the stools to the 
medical officer, even if there are no other disorders 
or diarrhea. 
10. Attention must particularly be paid to every 
soldier washing his hands after defecation. If possible, 
this should be done in order to avoid any danger to the 
unit, 
B.) The disposition to infection must be reduced by: • 
1. A sufficient and suitable diet. 
2. Prophylaxis to avoid diseases due to cold and 
other diseases by providing abdominal protectors, a suf- 
ficient supply of blankets and warm clothing. It is im- 
portant to insist on an appropriate use of such items 
according to the orders. 
3. It is necessary to give repeated short and 
impressive instructions to the men during which reference 
should be made to local conditions. During the hot months 
of summertime all measures should be carried through with 
particular care.